12580 SW 121ST AVENUE 12580 SW 121'' Avenue
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CITY OF TIGARD 24-Hour
EUILDING Inspection Line: (503) 639-4175 MST
INSPECTION DIVISION Business Line: (503) 630-4171 BUP
Rb�e;ded —. -_-- Date Requested ( —L L- AMS M --- BLIP ------ ---------
Location —_ ?— --_- Suite—. MEC. __-- -----
Contact Pers,cn Ph(— ) - PLM —�1-2
Contractor __-- Ph( ) G= Via- -73 2 3 swr, ` �! `0o r yo
BUILDING _ Tenant/Owner --— is LC ----.----- ---
Footing ELC --
Foundation Access:
Ftg Drain ELR
Crawl Drain SIT
Slab Inspection Notei: _ -- - -- -
Post&Beam -- _ - —- - - --------
Shear Anchors
Ext Sheath/She-ir -_ _--
Int Sheath/Shear
Framing -- --- --
Insulation
Drywall Nailing - - - ---
F firewall -__-
Fire Sprinkler _
Fire Alarm
Susp'd Ceiling _-- -
Roof
Other: -
Final
PASS PART FAIL
PLUMBING -- --
Post&Beam—
Under Slab -
Rough-In
Water Service
ewe - -----
a n rains - —
Catch Basin/Manhole
Storm Drain --
Shower Pan
Fin --
S AR_T_FAIL
_ ANICAL
Post&Beam
Rough-in
Gas Line
Smoke Dampers —
Final _
PASS PAR* FAIL --
ELECTRICAL
Service
Rough-In -
UC1/Slab
Love Voltage --
FL-c Alarm
Final Reinspection fee of$. _ -_required before next inspection. Pay at City Hall. 13126 SW Hall Blvd.
PASS _PART FAIL
Please call for reinspection RE:—._-. F-1 Unable to Inspect-no access
Fire Supply Line 71Z
ADA patooz
L _ Inipoatori �Y ext
Approach/Sidewalk
Other: ---
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART F!IL
1 CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2002-0012.0
13125 S'V Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 4/12/02
SITE ADDRESS: 12580 SW 121ST AVF PARCEL: 2S103BD-01001
SUBDIVISION: ZONING: R-4.5
BLOCK: _ LOT: __ _ JURISDICTION: TIG
CLASS 01= WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES _ LAUNDRY TRAYS: Sr RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 18 ft
WATER CLOSETS: WATER L UE: ft
DISHWP'F'iERS: RAIN DRAIN: ft
Remarks: Installation of approx mately 18 feet of sewer line and reversal of plumbing under'.he house to connect to newly
installed sewer lateral, Septic tank is to be l umped, filled and inspected. RelmhUrsemfmt District#18 fee paid
on this date.
Owner: _ _ FEES
HUGHES,JACK D TR + Type Ely Date Amount Receipt
HUGHES,LEONE M TR PRMT CTR 4/12/02 $105 00 27200200000
12580 SW 121 STAVE 5PCT CTR 4/12/02 $8.40 27200200000
TIGARD, OR 97223 Total $113.40
Phone 1: 503-590-7861
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: Sewer Inspection
Reg#: Misc. Inspection
Final Inspection
This permit is issued -,,Ibject to the regulations contained in the Tigard Municipal Code, State of OR.
Sp-)cialty Codes and all other applicable laws. All work will be done in accordance with approved plans.
Tnis permit wail expire if work is not started within 180 days of issuance, or if work is suspended for mots
than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon, Utility
Notification Center. Those rules are set forth in OAR 9b2-0001-0010 through OAR 952-0001-0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246-1987.
Issued B : �,/ ✓,
y 1 r !.�
Permittee Signature:-� _-� -- Lr�c s..t ` Y ^
Call (503) 639-4175 by 7:00 P.M. for an inspection needed tate next business day
r
Plumbing Permit Application
Date received: �01 o;:L- Permit no.:
City of Tigard Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd,Tigard,OR 97223 —
City ofTigard Phone: (503) 639-4171 Project/ap;1.no.: Expire date.-
Fax:
ate:Fax: (503) 598-1960 Date issuer: B� Receipt no.
Land use approval: _ Case file no.: Payment type.
WA W 1
JA&2 family dwelling or accessory U Commyfelal/irtdustoA U Multi-f'MAN, U'I'cnanl inti rrw�tnrnt
U Nvw conslructirm U U Food se vier U()then. —�--
-300 SITE INF01MATIorifi t
/ Job address: J�� /fir ST_'a - _ Description Qt hec(ea.) 'Total
Bldg.no.: I Suite no.: Nen I-and 2-family dwellings only:
(Includes 100 ft.far each uliM y connection)
Tux map/tax lot/account no.: SFR(1)bath
Lot: Block: Subdivision: _ - _-- --
SI-R(2)bath ------
Project name: _ SPR(3)bath
City/county: ZIP: Each additional bath/kitchen '
Description and loca 'on of work on p miser: Siteutilities:
4.g- u,)Q `t Catch basin/area drain
Ian.(late of completion/inspection: Drywehs/leach line/trench drain _
Footing drain(no.lin.ft.)
n Manufactured home utilities _
Business ozone: UI.0 N�P� Manholes _
Address: Rain drain connector _
City: State: ZIP: Sanitary sewer(nn, lin.ft.
Phone: Fax: E-mail: Storm sewer(no.lin. ft.) _ _ t,.
CCB no.: Plu_mh hrts.reg,no:
H'aUxservice(no. lin. ft.)
City/metro lie.no.:
Fixture or Item:
Contractor's representative signature: Absorption valve _-
Print name: Date: Back flow preventer _ _—
Backwater valve _
Basins lavatory _
Name: Clothes washer -
Dishwasher
Address: Drinking fountain(s) —
City.. Stat(: ZIP: E'ectors/sum
Phone: Fax: E-mail: Expansion tank
Fixture/sewer cap i
Name(print): "j t-CtJ G Floor drains/floor sinks/hub -
Mailing address: p 1 Garbage disposal
City: k�(a State 2 ZIP: 3 Hose bibb --
_��,—— — ce maker
Phone: ^-7 Fax: Email: nterce tor/ cease trap
Owner iiistallation/residential mair...iant:e only: The actual installation Primer(s) _
will be made by me or the maintenance and repair made by my regular Roof drain(commercial)
employec on the pro arty I wn per ORS Chapter 447. Sink(s),basin(s),lays(s)
Owner's signature: Zr t__. Date: A Com" Sum - —
Tubs/showcr/shower an
-- ---Name: Urinal
------- - ---- ---- Water closet
Address: W ate heater
City: - State: Other:
Phone: —-- _ Fax: Email: Mai
No all jutisdictions accent credit cards,please call jurisdiction fat more infattWion. MiniRlum fee................$ _L..0 S• _
Notice:This permit application
U Visa U MasterCard Plan review(at __ %) $
expires if a permit is not obtained
Credit card number:- -_ _IL within 180 days after it has been State surcharge(8%)....$ _
tispirrs 13, y
- — accepted as complete. TOTAL .......................$
Name of cardholder a shown nn credit cud p p _
S
('ardh4A r silnalure Amunl
M(I�K+161 iOatCUM)
PLUMBING PERMIT FEES:
PRICE '--TOTAL New-1 and 2-family dwellings only: -
TOTAL
FIXTURES (individual) QTY ea AMOUNT (includes all the dwelling and tbinghe fixtures
iix urs In CITYP(ea) AMOUNT
Sink 16.60
16.60 for each utility connection
Lavatcry _ _Onc 9bath - $249.20
Tub or Tub/Shower Comb. 16.60 TwogLbalh _ $350.00
Shower Only
16.60 Three(3)bath
_
Water Closet 16.60 - _ _ SUBTOTAL
Urinal 16.60 _ 8%STATE SURCHARGE
-- PLAN REVIEW 25%OF SUBTOTAL
Dishwasher 16.60
- TOTAL
Garbage Disposal 16.60 - --- - -- -- -" - - - -
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" -- 16.60 PLEASE COMPLETE:
g" 16.60
q^ 16.60 --
Water Heater ir conversion O like kind 16Quantit b Work Performed.60 Fixture Type: New-coed Replaced Removed/
Gas piping requiress a a separate mechanical Ca ed
ermit. Sink
MFG Home New Water Service 46.40
MFG Home New San/Storm Se.;er 46.40 Lavatory
_ Tub or Tub/Shower
Hose Bibs 16.60 _ Combination
Roof Drains 16.60 Shower Only _ ----
16.60 Water Closet - -----
Drinking Fountain Urinal _ --
Other Fixtures(Specify) 16.60 Dishwasher - --�
Garbage Disposal
Laundry Room Tray
Washina Machine
Floor Drain/Sink: 2"
Sewer-1 sl 100' 5500 ,j 5 UO 3" -
Sewer-each additional 100' 46.40 4„ - - --
Water Service tel 10055.00 Water Heater -
Other Fixtures
Water Service-each additional 200' 46.40 S eci - - -
Storm&Rain Drain-1st 100' 55.00 -
Storm&Rain Drain-each additional 100' 46.40 -
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 16.60 -
Inspection of Existing Plumbing or Specially 62.50 COMMENTS REGARDING ABOVE:
Re ueated Ins actions er/hr
Rain Drain,single family dwelling 05.25
Grease Traps 16.60 -- - - `-
dUANTITY TOTAL _
Isometric or riser diagram Is required it
CveniNy Total Is >a _ __ --
*SUBTOTAL - -
8%STATE SURCHARGE
"PLAN REVIEW 25%OF SUBTOTAL
Requirbd only If fixture qty total Is>B
TOTAL S
.Minimum permit tad Is$72 50+6%state surcharge,except Residential Backflow
Prevention Device,which Is$38 25+a%stain surcharge
~All Now Commercial Buildings require 2 sets or plans with isometric or riser
diagram for plan review.
I:\dsts\forms\plm-feen.doc 12/26/01
CITY OF TIGARD SEWER CONNECTION PERMIT
/
DEVELOPMENT SERVICES PERMIT#: SWR2002-00140
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 4/12/02
PARCEL: 2S103BD-01001
SITE ADDRESS; 12530 SW 121 ST AVE
SUBDIVISION: ZONING: R-4.5
BLOCK: LO'r: JURISDICTION: TIG_
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS.
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Romarks: Connect existing house to newly installed sewer lateral.
Owner: _ FEES ^'
HUGHES, .JACK D TR + Type By Date Amount Receipt
HUGHES, LEONE M TR
12580 SW 121 ST AVE PRMT CTR 4/12/02 $2,300.00 27200200000
TIGARD, OR 97223 INSP C1 R 4/12/02 $35.00 27200200000
Phone: 503-590-7861 u Total $2,335.00
Contractor.
OWNFR
Phone:
Reg #:
Required Inspecticns
Sewer Inspection
Septic Tank Filled
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterels. If the sewer is not located at the measurement given, the installer prospect
3 feet In all directions from the dis'F nee given. If not so located,the installer shall put chase a "Tap and Side Sewer' Perm
r
Issue / by: ILI
1 1 Permittee Signature: G�-s
,
Call (503) 639-4175 by 7.00 P.M. for an Inspection needed thdnext business day `
� . A-AFFORDABLE
SEPTIC SERVICE
PO.BQX 1130
WILSONVILLE,OR 97070
0;3)682,J929 FAX(503) 57J-0779
CUSTOMER'S ORDER NO PHONE DATE
NAME LLL
(
ADDRESS
P,
SOLD BY CASH I C.O.D. CHARGE ON ACCT. MDSE.FIET'D. PAID OUT
CITY DESCRIPTION PRICI AMoi jr4 i
I-t ri
TAX
RECEIVED SY
TOTAL
J
U cloimq mrd&"m 040matu compon*d by th Is bill
THANK YOU