13430 SW 121ST AVENUE 1
13430 SW 121" Strut
Ciary OF T GAR® SEWER CONNECTION .-ERM IT
DEVELOPMENT SERVICES PERMIT#: S 00344
12125 SW Hall BI,.J., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 12//2410224/02
PARCEL: 2S 103CA-01900
SITE ADDRESS; 13430 SW 121ST ST
SUBDIVISION: WOOUCREST ZONING: 1t-1.5
BLOCK: LOT: 002 JURISDICTION: Tio _
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:
Remarks: Connect to sewer. Septic tank to be pumped or filled a;id inspected
Owner: _ — FEES
WILLIAMS, PETER ERNEST Description Date Amount
AND JEAN -
13430 SW 121 ST SWUSA]Swr Connect 12!24/02 $2,300.00
TIGARD, OR 97223 �SWUSAISwr Connect 12/24/02 $0.00
Phone: ISW1NSPj Swr Inspect 12/24/02 $35.00
[SWiNSP)Swr Inspect 12/24/02 $0.00
Contractor: --
---------- — Total $2,335.00
TED MCBFf_ FXCAVAIING INC
11426 Nr.. SCHUYI I-R
PORI LAND, UIQ 97,120
Phone: 939-5246
Reg #: LIC 110314
Required Inspections
Sewer Inspection
Septic Tank Filled
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. 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 seA er laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located,the installer shall purchase a"Tap and Side Sewer" Perm
Issued by: � 'Y _ Permittee Signature: ,L: /✓�. ,,,,
for an inspection needed the It business daCall (503) 6 -41T5 by 7:00 P.M pY
Building Fixtures
Plumbing Permit Application '
Date received: /oZ Permit no.:5(�J
City of Tigard Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd,Tigard,OR 97221
City.?fTigard Phone: (503) 639-4171 Project/appl. no.: Expire date:
Fax: (503) 598-1960 Date issued: By: Receipt no.:
Land use approval: _ Cass file no.: Payment type:
❑ I &2 family dwelling or accessory ❑Commercial/industrial U Multi-family Ll Tenant improvement
O New construction ❑Addition/alteration/replacement U Food service LIOther:
Job address:( 3_+ ( hi i- " A�r "f( lT N-� Description_ Qty (ca.) 'Iofnl
Netti 1-and 2-family dwellings only:
Bldg, no.: Suite no.:4 1111
(Includes 1 ft.for each utidit}counec(iou)
Tax map/tax lot/account no.: .:L-5 1 3 C I9 O SFR(1)bath
Lot: 2 Block: Subdivision: w t;u J C Iti(S: T SFR(2)bath
Project name: SFR(3)bath
City/county:— (, -ZIP: IZ Each additional bath/kitchen
Description and location of work on premises: (L Siteutilities:
Catch basin/area drain
Est.date of collipletioc/inspection: Dwells/leach line/trench drain
Foryoting drain(no.lin.fl.)
PLUMWING f Manufactured home utilities
Business name:-I ( (' V. ( Manholes
Address: tti -, '�_ Rain drain connector
City: UStatea IL ZIP:c -1 2,1.O Sanitary sewer no.lin, R.)
Phone ;" y 2. Fax: y- a p E-mail: Storm sewer(no.lin.it.)
CCB no.. ii Plumb.bus.reg. no: Water service no.lin,ft.
City/metro lic.no. 11wire or Item:
Absorption valve _
Contractor's representative signature: Back flow preventer _
Print name: Date: Backwater valve
Basins/lavatory
Name: �.H r tS h�G�� -,K� � Clothes washer
Dishwasher
Address: Drinking fountains)
Cit _ _ State_ ZIP_._ _ Ejectore/sump
Phone: r,%s vyti 1 Fax: 1' n,•ril Expansion tank _
Fixture/sewer cap
Name(print): r'C E 1� o -;a` ►,t � �t A r,`.
Floor drains/floor sinks/hub
t -s
v — Gar a e disposal
(J` Mailing address: 1 , L) ;J_j 2_1' Hose bibb
City: TI' 1\ 12 0 1 State:CII- LIP.y-1�24 2112- Ice maker
Phon :5t.3 '40 41;t, Fax:_ I E-mail: Interceptori,Rrease trap —
Owner instal lation/residential maintenance only: The actual installation Primer(s) _
will be made by me or the maintenance and repair made by my regular Roof rain(co-nmer— ciaT--
employee on the propetty I own as per ORS Chapter 447. Sink(s),basin(s),lays(s)
Uwrier's signature: :•+. _ Date: r Sump _
Tubs/shower/s ower pan
Urinal
Name_,•, f h�"t:t _ Water closet
Address: Water heater
aty: - mete_: o—t -----
Phone• Fax: E-mail: Total
Minimum fee................S
Not all durisdittions accept cmdil cards,piton all jurisdiction for more infomntion. Notict Thin permit application
Plan review(at_ °rb) S
U vim O MasterCard expires if a permit is not obtained State surcharge(8%)... $
Credit card numberapNn within 180 days after it has been
Name of car o r u shown on credit card
- accepted as complete. TOTAL........................ S �—
Cowlinider siputure s Amount 440-4616 I6fl00YCOM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2-family dwellings cnly: -�
FIXTURES (individual) QTY ea AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink 16.60 [the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory ~w 16.60 - for each utili!y connection)
One 1 bath _ $249.20
Tub or Tub/Shower Comb. _ 16.60 _ Two 2 bath _ $350.00
Shower Only 16.60 Three(3)bath _ $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8%STATE SURC14ARGE _
Dishwasher 16.60 PLA_N REVIEW 25%OF SUBTOTAL
Garbage Disposal 16.60 ____ __TOTAL
Laundry Tray �- 16.60
Washing Machine 16.60
Floor Drair/Floor Sink 2" 16.60
PLEASE COMPLETE:
3- 16.60
4" 16.60
Water Heater O conversion O like kind 16.60 _ Quantity b i Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. -- Capped
MFG Home New Water Service 46.40 Sink -
MFG Home New San/Storm Sewer 46.40 Lavatory
Tub or Tub/Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 r;,ower Only
Drinking Fountain 16.60 'w'iter Closet ^
Other Fixtures(Specify) 16.60 -
J shwasher _
Garbage Dis osal
Laundry Room Tray -
Washing Machine
Floor Drain/Sink: 2"
Sewer-1st 100' 55.00 3„ -- - -"
Sewer-eech additional 100' 46.40 4"
Water Service-tat 100' 55.00 Water Heater
Water Service-each additional 200' 46.40 Other Fixtures
(specify)
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 -J{
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections perthr COMMENTS REGARDING ABOVE:
Rain Drain,single family dwelling 65.25
Grease Traps 16.60 - --------- -
QUANTITY TOTAL
Isometric or riser diagram in required It �� J
Ouanlliy Total Is a 9 --*SUBTOTAL
8%
8%STATE SURCHARGE ------ -- ---
"PLAN REVIEW 25%OF SUBTOTAL
Ro ulred unly If fixture qty total is,9
TOTAL E
*Minimum permit fes Is$72 50 4 E%state surcharge,except R.esidenllal Beaktiow
Prevention Device,which Is$ae 25•E%state surcharge
**All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
1:\dstslforms\plm-fees.doc 12/26/01
CITYSOF T'IGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: P8/03 -00031
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 1/228/03
PARCEL: 2.S103C'A-01900
SITE ADDRESS: 13430 SW 121ST ST
SUBDIVISION: WOODCREST ZONING: R-4.5
BLOCK: LOT: 002. JURISDICTION: TIG
CLASS OF WORK: AL r 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: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 60 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install 60ft, of sewer line to connect to lateral. Septic tank to be pumped, filled and inspected.
FEES
Owner:
_
Owner:
— Description Date .mount
WILLIAMS, PETER ERNEST
AND JEAN II1LUM13J Permit Ice 1/28/03 $72.50
1 3430 SW I. '3T ITAXI 8%State I ox 1/28/03 $5.80
T GARD, OR 97223 Total $78.30
Phone :
Contractor:
TED MCBEE EXCAVATING INC
11428 NE SCHUYLER
PORTLAND, OR 97220 REQUIRED INSPECTIONS
Sewer Inspection
Phone : 939-5240 Final Inspection
Reg#: LIC 110314
This permit is issued subject to the regulations contained in the Tigard Municipa; Code, State of OR.
Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans.
This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more
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 952.0001-0010 through OAR 952-0001-0100.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246-6699.
Issued B , , �' ��f� Permittee Signature: ��
y 1,2x,.1 �� I
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
ONLY
PlftlCA bind Perinit kpplicationl Received , , 'FFICEAISF Plumbing
Date/By: -%>'51,ermit No.:
Planning Approval Sewer
City of T Igard Date/13y: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard,Oregon 97223 Date/By: Permit No.:
Phone: 503-639-4171 Fax: 503-598-1960 Post-Review Land Use
Date/By: Case No.:
Internet: www.ci.tigard.or.us Contact Juris.: Sec Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Melhod: _ Su lemental information._
TYPE OF WORK FEE*SCHEDULE(forspecial Information use checklist
New_constniction I ❑ 1-emolition Description I Qty. I Fee(ea-) f Total
Addition/alteration/re lacement I [l Other: New 1-&2-family dwellings
Includes 100 ft.for each unlit connection
CATEGORY OF CONSTRUCTION SFR I Uli 249.20
1 &2-Family dwelling Commercial/Industrial SFR 2 bath 350.00
Accessory Building Multi-FariiI _ SFR 3 bath 399.00
[] Master Builder Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Firesprinkler-sq.ft.: Pa c 2
Job site address: j w to Site Utilities
Suite#: Bld ./A t.#: Catch basin/arca drain IG.60
Dr ell/leach line/trench drain 16.60
Project Name: 10. Footin r ft.drain no.lineaPae 2
Cross street/Directions to job site: Manufactured home utilities 110.00
Manholes _ 16.60
S
1 Rain drain connector 1 16.60
Sanitary sewer no,linear ft. Pae 2
Subdivision: Lot : Storm sewer no. linear f1. Pee 2
Water service(no. linear ft.) PaF,c 2
Tax map/parcel #: Fixture or Item
_ DESCRIPTION OF W0 K Absorption valve --�J- 116.60
Backflow prevcnter Pae 2
C _ Backwater valve 16.60
Clothes washer 16.60
- ---- ---- - - - - Dishwasher 16.60
--
Drinking fountain - 16.60
PROPERTY OWNE 10TENANT Ejectors/sum 16.60
Expansion tank _ 16.60
Address: ?v t-{ Fixture/sewer cap 16.60
CityiState/Zip:` Floor drain/floor sink/hub 16.60
Garbage disposal 16.60
Phone: cin Fax: Hose bib 16.60
APPLI-C�- CONTACT PERSON Ice maker 16.60
acne: E1 c- Interco tor/ rcase trap 16.60
Address: Medical gas-value: $ Pa c 2
- -----� Primer 16.60
Cit /State/Zip: _ Roof drain commercial _ 16.60
Phone: ax: Sink/basin/l3vato _ _ i6.60 _
E-mail: Tub/shower/shower pan 16.60 _
CONTRACTOR Urinal 16.60
Business Name: C
Water`loser 16.60
Water heater 16.60
Address: Other:
City/State/Zip: c Other:
Phone: Fax: Plu!n i Perinit Fees"
Subtotal S
CCB Lie. #: t- Plumb. Lic.#: _ Minimum Pemiii Fee 572.50 S
Authorized Residential Backflow Minimurn Fee$36.25
Signature: Aare•� � Plan Review 25%of Permit Fee $
State Surcharge(8%of Permit Fee) S
(!'least print mute) TOTAL PERMIT FEE S -7
Notice: This permit application expires If a permit Is not obtained within All n-w commercial buildings require 2 sets of pians with Isometric or
IRO days after It las been at epled as complete. riser diagram for plan review.
*Fee melhodtdogy set by Tri-County Building Industry Service Board.
i,N)stoemut ForrnsTlmPrrmitApp doc 01103
Plumbing Permit AP_nlicati0n - City of Tigard
Page 2 -Supplemental Information
Fee Schedule: Residential Fire Su ression Systems:
Site Utilities Q(y. Fee(ca) total Square Footage: Permit Fee:
Footing drain- I" 100' 55.00 0 to 2,000 _ $115.00
46.40
2,001 to 3,600 $160.00
Footing drain-each additional 100' 3,601 to 7,200 $220.00
Sewer- I st 100' 55.00 7,201 and greater_ $309.00 _
Sewer-each additional 100' 46.40
Water Service-Ist 100' 55.00 Medical Gas S StCms:
Water Service-each additional 100' 46.40 Valuation: Permit Fee:
Storm&Rain Drain-Ist 100' 55.00 $1.00 to$5,000.00 Minimum fee$72.50
Storm&Rain Drain-each additional 100' 46.40 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for each
additional$100.00 or fraction thereof,to and
Fixture or Item Qty. Fee(ea) Total including$10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for
each additional$100.00 or fraction thereof,to
Residential Backflow Prevention Device and including$25,000,00.
minimum rmit fee$36.25 27.55 _
$25,001.00 in$50,000.00 $379.50 for the first$25,000.00 and$1.45 for
Rain Drain,single family dwelling 6515
_ each adJitional$100.00 or fraction thereof,to
Inspection of existing plumbingjor and includin $50 000.00.
s ciall rc uested ins ctionshour 72.50 _ $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
Subtotal: each additional$100.00 or fraction thereof
Fixture Work:
Are you capping,moving or replacing existing fixtures? 11'
"yes",please indicate work performed by fixture. Failure to
acet iratelv report fixtures could result in increased sewer teW. t ttttttt�e„t, ref ar,lin{; fixture r�orl::
uanlll b Flxturc York 11crforored
Flxlure Type: Replace
New Moved Fxbtln Ca fed - -
Baptistry/Font -------.----
Bath -Tub/Shower
Jacuzzi/Whirlpool
Cor Wash •Each Stall
-Drive Thru
Cuspidor/Water Aspirator
Dishwasher -Commercial
-Domestic
Otinking Fountain
E e Wash
Floor Draiw'sink 2"
.3"
4"
car Wash Drain "Note: if the fixture work under this permit results in .In
Garbage -Domestic increase of sewer EDUs,a sevser pe.-init will be issued and
Disposal -Commercial fees assessed for the sewer increase must be paid before the
-Industrial
Ice Mach./Reffig Drains plwt+.bing permit can be issued.
Oil Separator Gas Station
Rec,Vchicle Dump Station
Shower -clang
-Sall
Sink -Bar/Lavatory
-Bradley
-Commercial
-Service
Swimming Pool Filter
Washer-Clothes
Water Extractor
Water Closet-Toilet
Urinal
Other Fixtures
i\Usts\Permit Fornv\PlmPermitAppPg2.doc 01103
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175
INSPECTION DIVISION Business Line: (503)639-4171 MST
BUP ..--._--
Received �- Date Requested_-_-_ _ _ AM PM _ _ BUP
Location 13. 3o .—__Lf�1_-`4t7 Sui _ MEC
Contact Person _ Ph( ) 3�" J PLM f?O �OOd
Contractor _ -_ _� -___- _ Ph( ) — SWR
BUILDING Tenant/Ownar _ - A_ ELC
Footing
Foundation ELC
Fog Drain Access: -
`�- (� ( J� ELR
Crawl Drain
Slab Inspection Notes: ;Lr 5 ; , 2_00_ cr r�` (�� `SIT
Post&Beam - �`''
Shear Anchors ----- -- -
Ext Sheath/Shear
Int Sheath/Shear
Framing -
Insulation
Drywall Nailing --- - - --
Firewall
Fire Sprinkler -
Fire Alarm
Susp'd Ceiling �.. --- -- --- -
Roof
Other: - - --
Final
PASS PART FAIL -
_PLUMBING_ __ _
Post&Beani
Under Slab
Rough-Ir. /
Water Service
1 rani
R - -
Catch Basin/Manhole
Storm Drain ---- --
Shower Pan _
Other:_ 1
F
-FAIL - -
lCAL
Post& Beam
Rough-In
Gas Line
Smoke Dampers -
Final
_PASS PART FAIL - -- - ----- --
ELECTRIC_AL
Service ^-
Rough-In _
Ufa/Slab
Low Voltage
Fire Alarm
Final Reinspection fee of$__ required before next Ins
PASS PART FAIL iJ p 4 pection. Pay at City Hall, 13125 8W Nell Blvd.
SITE Please call for reinspect n RF:_ - - -.- E]Unable to inspect-•no access
Fire Supply Line
ADA
Approach/Sidewalk DOW Inspector... _ txt
Other:_—_-_ ___
Final DO NOT IRFMOVE this Inspection record frormn a job site.
PASS PART FAIL
fM' o invoice
GRIFFIS S"01 !'It; S1:1111l ."PE
1'741'13pE
Name — _= ---. ...__.. . -
T
Address_1_ _�13a Su)l—1-r-), ___._ Phone
city—
State
ity—State _ Zip Code
Price Amount
�A? A) 0 14 Foul
NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING _
• A service charge of t.504.will be levied on all past due accuuntsr Total; J12'! �O
• Returned check fee is$20.00,
• In case suit, action or arbitration is instituted by either party for breach or to enforce any —
provisions herein, the court shell award reasonable attorney's fees and actual costs to the
prevellin party at trial or arbitration, or upon any appeal taken therefrom
l A
Appr val
dy
Customer SW41urs
?'dank You PO Box 1136 • Canby, OR 97013 DEQ#37464
(503) 263.2087 or (503) 632-6138 CCS# 104320
TO 39Vd 339DW 311315 BZ09TGZEOG EG:TO L661/9Z/00