13470 SW HOWARD DRIVE I1
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13470 SW HOWARD ST ---
CITYOF TI GARD _ SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT#: SWR2003-002811,1
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUEC: 7/14/03
SITE ADDRESS; 13470 SW HOWARD ST
PARCEL: 2S 103CA-01800
SUBDIVIS.ON: WOODCRI ti l ZONING: R-4.5
_ BLOCK: LOT: 003 — JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTAL L. TYPE: LTPSWR IMPC-RV SURFACE:
Remarks: Connect existing house to sewer lateral. Reimbursement dist. #22 paid.
Owner: !—___-----
_— FEES___
TUCKER,ANTHONY K AND
JOYCE E Description Date Amount
13470 SW HOWARD DR [SWUSA] Swr Connect 7/14/03 $2,400.00
TIGARD, OR 97223 [SWUSA]Swr Connect 7/14/03 $0.00
Phone: 503-590-3557 [SWINSP]Swr Inspect 7/14/03 $35.00
Contractor:
SWINSP] Swr Inspect 7/14/03 $0.00
- -
Total $2,435.00
Phone:
Reg#:
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 sewer 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: .�c. G {.�. .. ��; �, C_ Permittee Signature:
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
Build ; Fixtures
FOR OFFICE USE eNIX
Min, 1 -frM"pyliegion Received
ri,I,,,),I„t;
Date/By: _ Pern,it_No, _
City of Tigard Planning Approval Sewer g-
natc/11 : Pcrmit No.:�I rl r�2GY13 -OU�Bg
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 loris.: see Page 2 for
24-hour Inspection Request: 503-639-4175 Name/Method: tiu Icmcntal Information.
TYPE OF WORK fv FEE*SCHEDULE(for special information use checklist
E
New construction Demolition Description qty. Fce(ea.) I Total
Addition/alteration/re lacement LJ Other: New 1-&2-family dwellings
CATEGORY OF CONSTRUCTION includes 100 ft.for each u Ility connection
1 &2-Familydwelling Commercial/Industrial SFR I bath 249.20 v I
weS _ _.. SFR 2 bath 350.00
Accessory Buildin Multi-Family SFR(3)bath 399.00
Master Builder LJ Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATION Firesprinkler-sq. ft.: Page 2
Job site address:,3 e2 S•D7wo'✓7'i— 6 K. Site Utilities
Suite#: Bldg./Apt.#: Catch basin/arca drain IG.GO
Pro'ect Name: Dr ell/leach line/trench drain 16.60
Footing drain no.linear ft.) Pae 2
Cross street/Directions to job site: Manufactured horrtc utilities 110.00
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer no. linear ft. Page 2
SubdivAil'on: _ _ Lot it: Storm sewer no.linear ft. -' Pae 2
Tax map/parcel #: Water service(no. linear ft. v Page 2
Fixture or Item
DESCRIPTION OF WORK Absorption valve � - 16.60
` ZCE' �d�j//f/�t^(/rJ� Backflow prevcnter Pae 2
Backwater valve 16.60
Clothes washer _ _ 16.60
-----� —-- — Dishwasher _ 16.60 _
Drinking fountain 16.60
PROPERTY OWNER TENANT Ejectors/sumpi� 16.60
Name: A, ;rfoNY k, to v-C- Expansion tank 16.60
Address: 13 L{7 O S.LJ I-IOLfire 0 p I? Fixture/sewer cap 16.60
City/State/Zip: Tke ti41F t.� 0 2 (1-7 22 3 Z`t 1:;r, Floor drain/floor sink/hub 16.60
-�------ Garbage disposal IG.GO
Phone:sO3 lc:! s , Fax: Hose bib 16.60 _
APPL C CONTACT PERSON Ice maker _ 16.60
Narne: Interce tor/ rease trap _ 16.60
Address-. _ Medical as-value: S Pae 2
_
City/State/Zip: Primer 16.60
_ 16.60 — -
Roof drain(commercial
_
Phone: ( ax: Sink/basin/lavato 16.60 -
E-mail: Tub/shower/shower pan 16.60
CONTRACTOR Urinal 16.60
Business Name: Water closet _ 16.60
- ---_..__----..-..--------- .._ -._-_- Water heater 16.60
Address: —_ --- -- _-_ -Other:
City/State/Zip: Other: _
Phone: Plumbing Permit Fees*
CCB Lic. #: Plumb. Lic.#: _ Subtotal $ —
Minimum Permit Fee$72.50 S
Authorized Residential Backflow Minimum Fee$36.25
Signature:(i,,; ,, ,111 �w tc _ Date:' -tc1-i•r '-3 _ Plan Review 25%of Permit Fee) S —
State Surcharge 8%of Permit Fee $ _
(Please print name) _TOTAL PERMIT FEE S
Notice: I his permit application expires If a prroili is not obtained Hithin All new commercial buildings require 2 sets of plain with isometric or I
180 Balt aftel it Ila%been accepted as Complete. riser diagram for plan review.
"fee methodolog) set by Tri-County Building Indusia Service Board.
i:\l)sts\Pemut FormsTImPemfltApp.doc 01/t)1
Plumbing_Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fired ression Stems:
Site Utilities Qty. Fcc(ea) Total S uare Footage: Permit Fee:
Footing drain-I" 100' 0 to 2,000 $115.00
Footing drain- -ach additional 100' 46.40 2 001 to 3 600 $160.00
_ 3,601 to 7,200 _ $220.00
Sewer-1st 100' 55.00 7,201 and greater $309.00
Sewer-each additional 100' 46.40
Water Service-1st 100' 55.00 Medical Gas S stems:
Water Service-each additional 100' 46.40 Valuation: Permit Fee:
Storm&Rain Drain-1st 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
Residential Backilow Prevention Nvice each additional$100.00 or fraction thereof,to
minimum permit fee$36.25 27.55 and including$25,000.00, ---
Rain Drain,single family dwelling 65.25 $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 fi•r
each additional$100.00 or fraction thereof,t:
Inspection of existing plumbing nr and including$50,000.00.
s ecially requested inspections-pet hour 72.50 $50,(N11.00 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? If
"yes",please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*.
uantit b (Flzlura)Work Performed Comments regarding fixture work:
Fixture Type: Replace _
New Moved Existing Capped
Ba tistry/Pont
Bath -Tub/Shower -
-Jacuzzi/Whirl ool --
Car Wash -Fath Stall
-Drive Thru _
Cuspidor/Water Aspirator
Dishwasher -Commercial
-Domestic
Drinking Fountain
Eye Wash - --- --
Floor Drain/sink -2"
4„ -- --
__ Car Wash Drain *Note: If the fixture work under Ilds permit results in an
:ivhage -Domestic _—_—
Disposal -Commercial Increase of sewer EllUs,a sewer permit will be issued and
Industrial fees assessed for the sewer increase must be paid before the
Ice MachAefri .Drains plumbing permit can he issued.
Gil Separator Gas Station
Rec.Vehicle Dump Station
Showa -Gang
-Stall
Sink -Bar/Lavatory
-Bradley
-Commercial
-Service
Swimolina Pool Filter
Washer-Clothes
Water Extractor
Water Closet-Toilet _
Urinal
Other Fixtures:
is\Dsts\Permit Forms\PlmPermitAppPg2.doc 01/03
f
\ CITY OF TIGARD _ PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2003-00357
-- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 7/23/03
SITE ADDRESS: 13470 SW HOWARD ST PARCEL: 2S103CA-01800
SUBDIVISION: WOODCREST ZONING: R-4 5
BLOCK: LOT: 003 JURISDICTION: TIG
CLASS OF WORK: NEW 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:
Y� SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 200 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of 200' or less of sanitary sewer service to connect existing house to sewer lateral. Septic tank is to
be purnped, filled and inspected.
FEES
Owner: J --�-----
- Description Date Amount
TUCKER, ANTHONY K AND
JOYCE E I I'LUNIIiI I'rrmit Fre 7/23/03 $101.40
13470 SW HOWARD DR I I '1\I M I,1 7/23/03 $8.12
TIGARD, OR 97223 _ Total $109.52
Phone : 503-590-3557
Contractor:
A-AFFORDABLE SEPTIC; SERVICE
PO BOX 1 30
WILSONVILL.E, OR 97010 REQUIRED INSPECTIONS
Phone : 503-969-9548 Sewer Inspection <
Insp existing/capped fixtures �,,1
Reg #: LIC 151481 Final Inspection A(P/f t ti Fact-ETj
This permit is issued subject to the regulations contained in the Tigard Municipal 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
Issued By: Permittee Signature:
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plum- binp- Permit .XppHcatlon Received //� , -
�-
Planning Approval Sewer
City of Tigard Date/By: Permit No.:
13125 S`•;I Hall Blvd. Plan Review Other
Tigard,Oregon 97223Dates: Permit No.:
Phone: 503-639-4171 Fax: 503-598-1960Post-Review Land Use
Datc/B : Case No.:
Internet: www.ci.tigard.or.us Contact Sr_e Page 2 fo-�
24-hour Inspection Request: 503-639-4175 Name/Method: //�'i' Su Icmental Information.
TYPE OF WORK FEE*SCHEDULE fora ecial information use checklist
New constructionDemolition Description Qty. F'ec(w.) Total
Addition/alteration/replacement I ❑Other: New l-&2-famn3,dwellings
CATEGORY OF CONSTRUCTION SIR
100:t.for each utI;It n
conection _
SI'R I bath 249.20
1 &2-Family dwelling LJ Commercial/industrial SFR 2 bath 350.00
Accessory BuildingHMulti-Family SFR 3 bath 399.00
Master Builder Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION and LOCATIO74 Firesprinkler-sq.ft.: Pa c 2
Job site address: 1-3117e Site Utilities
Suite#: Bld ./A t.#: Catch basin/area drain _ 16.60 _
Dr ell/leach line/trench drain 16.60 _
Project Name: Fooling drain no.linear ft. Pae 2
Cross street/Directions to job site; Manufactured home utilities 110.00
/7151' �-q/ Manholes 16.60
C Rain drain connector 16.60
Sanitary sewer no.linear ft. ' Pae 2 U
Subdivision: _ ��Lc t Storm sewer(no.linear ft.
tVision: #: Pege 2
Tax iv / n: #: Water service(no. linear fl.) Page 2
Fixture or Item _
DESCRIPTION OF WORK r Absorptionvalve16.60
Backflow reventer Page 2
Backwater valve 16.60 -`-
-- Clothes washer _ 16.60
- -- -- -- Dishwasher 16.60
_ Drinking fountain 16.60
PROPERTY OWNER 'TENANT Ejectors/sump 16.60
Name: A I Expansion tank 16.60
Address: 13 (&) r,�(�,� f�G1rlXrJc^!�_ Fixture/sewer cap 16.60
City/State/Zip: Floor drain/floor sink/huh 16.60
- -- ---- -
Garbage disposal 16.60
Phone: Fax: Hose bib 16.60
APPLICANT - CONTACT PERSON [cc maker 16.60
Name: _ lntcrcel3tor/grease trap 16.60
Address: �^ Medical gas-value: $ _ Pae 2
-- -�- Primer 16.60
City/State/Zip: Roof drain(commercial) 16.60
Phone: i av -- Sink/basin/lavatory 16.60
E-mail: Tub/shower/shower pan 1-r.60
CONTRACTOR - Urinal ;6.60
Business Name: Water closet 16.60
CC Water heater 16.60
Address: , C' Other:
city/State/Zi' tV Other:
Phony Fax: , r 7`� Plumbing Permit Fees*
Subtotal 5
CCBTi : /5 Plumb. Lie.#: Minimum Permit Fec$72.50 S
Authorized Residential Backflow Minimum Fee$36.25
Signature: Date: 7�. /� Plan Review 25%of Permit Fee,) 5
'711 A - - State Surcharge 8%of Permit Fee 5 i
(Please print name) TOTAL PERMIT FEE 5 r
Notice: This permit application expires if a permit IN not ohtained within All new commercial buildings require 2 sets of plans with Isometric or
180 dais after It has been arcepted as complete. riser diagram fo-plan review.
*Fee methodology,set by Tri-County Building Industry Service Board.
is\Dsts\Permit FormsTimi'cmutApp.doc 01/03
r
Plumbing Permit Application - City of Tigard
Page 2 -Supplemental Information
Fee Schedule: _ Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ca) Total Square Footage: Permit Fee:
Footing drain• I" 100' 55.00 0 to 2,000 _ $115.00
Footing drain-each additional 100' 46.40 2,001 to 3,600 $160.00 _
3,601 to 7,2 $220.00
Sewer-Ist 100' 55.00 7,201 and greatei $309.00
Sewer-each additional IOD' 46.40
Water Service-1st 100' 55.00 _ Medical Gas S stems'
Water Service-each additional 100' 4(,.40 Valuation: Permit Fee:
Storm&Rain Drain-1st 100' S5 00 $1.00 to$5,000 Minimum Ice$72.50
Storm&Rain[rain-each additional 100' 46 4n $5,001.00 to Vu $72.50 for the first$5,000.00 and$1.52 for each
Fixture or Item Qty. Fee(ca) Total additional$100.00 or fraction thereof,to and
including$10000.00.
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
Residential Backflow Prevention Device each additional$100.00 or fraction thereof,to
mmimum permit fee$36.25 27.55 and including$25,000.00.
Rain Drain,single family dwelling 65.25 $25,001.00 to$50,000,00 $379.50 for the first$25,000.00 and$1.45 for
- each additional$100.00 or fractior `ereof,to
Inspection of existing plumbing or and including$50,000.00.
s eciaIly requested inspections•per hour 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? If
"yes",please indicate work perforated by fixture. Failure to
accurately report fixtures could result in increased sewer fees*.
Quantity b Fixture Work Performed Comments regarding fixture work:
Fixture Type: Replace ---
_New Moved Exixtin Ca )cd
Baptist /Font
Ba, -Tub/Shower
-Jacuzzi/Wbirl of — --
Car Wash -Each Stall
-Drive Thru
Cuspidor/Water Aspirator —
Dishwasher -Commercial -
-Domestic
Drinking Fountain
Eye Wash -
Floor Drain/sink .2"
-Y ----.4,.
Car Wash Drain *Note: If the fixture work under this permit results it an
Garbage -Domestic
Disposal -Commercial increase of sewer EDUs,a sewer permit will be issued a,td
-Industrial fees assessed for the sewer increase must be paid before"he
Ice Mach./Refri .Drains plumbing permit can be Issued.
Oil Separator Gas Station
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink -lxarlt.avatory
-Bradley _
-Commercial
-Service _
Swimmina Pool Filter
Washer-Clothes
Water Extractor
Water Closet-Toilet
Urinal
Other Fixtures: _
ODsts\Permit Porms\Plml'crnmtAppl'g2.doc 01103
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)639-4175 MST —
INSPECTION DIVISION Business Line: (503) 639-41.
BLIP
Received Date--___ .-_ __ Date Requested_---__ '�f_—__ AM__ _PM __—____ BUP .._
Location _-1/-3 q 16 � — Suite MEC _._ ' n
Contact Person Ph( _) _L —�s PLM �11 d
Contractor - - -- -- Ph(--- —) — --- - SWR
BUILDING Tenant/Owner -__ _ _—— ELC
Footing ELC
Foundation Access:
Ftg Drain ELR --
Crawl Drain SIT
Slab Inspection Notes: -
Post&Beam _
Shear Anchors
Ext Sheath/Shear - - - --
Int Sheath/Shear
Framing --
Insulation
Drywall Nailing - -
r i-ewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling - - '
Roof
Other:
Final —
PASS PART FAIL —
PLUMBING
Post Beam -
Under Stab — - -
Rough-In _
Water S*ci — -
anitary Se --_ —
ein re ns --
Catch Basin/Manhole
Storm Drain
Shower Pan
AS PART FAIL
HANICAL - - -- --— --
YPost& Beam --- - _
Rough-In --- -
Gas Line _
Smoke Dampers --
Final -
PASS PART FAIL �—
ELECTRICAL
Service --
Rough-In —- -- - --
UG/Slab
Low Voltage —
Fire Alarm
Final Reinspection fee of$. _._ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection RE: Unable to inspect-no access
Fire Supply Line _I'-
__ ,
ADA Deto - _ Inspector ` WAt
Approach/Sidewalk _--
Other:_
Final DO NOT REMOVE this Inspection record from the job site.
PASS PART FAIL
/� CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES
PERMIT #. . . . . . . :
13125 SW Hall Blvd., Tigard, OR 97223 (503)639-4171 DATE ISSUED: 04/15/98
PARCEL: 25103CA-01.800
SITE ADDRESS. . . ; 1.3470 SW HOWARD ST
SUBDIVISION. . . . - WOODCREST ZONING: R-4. 5
BLOCK. . . . . . . . . . : LOI.. . . . . . . . . . . . . :003 JURISDICTION: URB
--1------------------------------------------------------------------------------------
CLASS OF WORK. . :ALT 13ARBA13E DISPOSALS. : 0 MOBILE HOME SPACES. : 0
TYPE OF USE. . . . :SF WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 0
OCCUPANCY GRP. . : R3 FLOOR DRAINS. . . . . . , 0 TRAPS. . . . . . . . . . . . . . . 0
STORIES. . . . . . . . : 0 WATER HEATERS. . . . . : 0 CATCH BASINS. . . . . . . : 0
F I X LAUNDRY 'T RAYS. . . . . : 0 SF RAIN DRAINS. . . . . : 0
SINKS. . . . . . . . . . 0 UR I NALS. . . . . . . . . . . : 0 GREASE TRAP'S. . . . . . . . 0
LAVATORIES. . . . : 0 OTHER FIXTURES. . . . : 0
TUR/SHOWERS. . . : 0 SEWER LINE (ft ) . . . : 0
WATER CLOSETS. : 0 WATER LINE (ft ) . . . : 50
DISHWASHERS. . . . : 0 RAIN DRAIN (ft ) . . . : 0
Remarks : Installing 501 of water, service
Owner-: -------------------------------------------------------- FEES
TONY TUCKER type amol.tnt by date rerpt
13470 SW HOWARD DR PRMT $ 30. 00 B 04/15/98 98-304965
TIGARD OR 97223 5PCT $ 1. 50 B 04/ 15/98 98-304965
Phone #:
Contractor-------------------------------------
CHRISTIAN PLUMBING
23172 SW STAFFORD RD.
TUALATIN OR 97062
Phone #: 503--638-8231 $ 31. 50 TOTAL
Reg #. . : 000426 REOUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the Water- Service In
Tigard Municipal Code, State of Ore. Specialty Codes and all other Final Inspection
applicable laws. All work will be done in accordance with
approved plans. This permit will expire if work is not started
within IN days of issuance, or if work is suspended for more
than IN days. AlUNTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those rules are
set forth in OAR 952-808I-88I8 through OAR 952-888I-988@. You may
obtain copies of these rules or direct questions to OIW by calling
(503)246-1967.
I ssi-ted L ly Permittee Signati.ir
+4-+4.4.+++++4.4-+-4...................4-++++4...........F...........4......4......4.++++++.4
Call. 639-4175 by 7:00 p. m. for an inspect ion needed the ne)(t fitisiness day
++.........++++4..........4-+++4..... ....4-1+++++-+-4F++4+4..........4'++'+......4-++++4
ITY OF TIGARD Plumbing Application Recd By, FWA
3125 SW HALL BLVD. Commercial and Residential Date Re I
IGARD, OR 97223 Date to P.E.Date to DST _
>03) 639-4171 Pennit 0 LL-F077_
Print or Type Related SWR
Incomplete or illegible applications will not be accepted Called -__-
Name of Development/Project On Indicate Work Performed by fixture.
Job FIXTURES (Individual) QTY PRICE AMT j
Address Street Address Suite Sink 9.00
3 tl '5 d-c.ca Dr Lavatory
- 9.00
Bldg* City/State Zip Pjb or Tub/Shower Comb. - 9.00
L:-4� �C.k-Q0 '??
Name Shower Only 900
Water Closet 9.00
Owner Mailing Address Suite Dishwasher 9.00
/3 0 5w (c--'' r Garbage Disposal
9.00
City/State ZIP Phone --
-N K. Washing Machine 9.00
o/ r^, > C? 3 S S' -
'- -Nar"4 Floor Drain 2" 9.00
" Atiti1 3" - 9,00
Occupant Mailing Address Suite v 4' 9.00
City/State ZIP Phone Water Heater O conversion O like kind - 9.00 -
Laundry Room Tray 900
-- Name urinal J 9.00
D Olher Fixtures(Specify) 9.00
Contractor Mailing Address Suiten
9.00
Prior to pernid City/State ZIP Phone _- 9.00
Issuance,a copy 0 ci,la w '(1, ?7r, ?//- cj y<./ 9.00
of all licenses are Oregon Const.Cont.Board Lir.,#t Exp.Date 9.00
required if 'Id 6.7 I Sewer-1 at 100" 30.00
expired In COT Plumbing Lic.S Earp.Dale Sewer-each additional 100' 25.00
database rj - )r1 - P)3 �� rjk
Name Water Service-1st 100' 30.00
Architect Water Service-each additional 200' 25.00
Or Mailing Address Suite Storm 6 Rain Drain-1st 100' 30.00
Storm&Rain Drain-c arh additional 100' 25.00
Engineer City/State ZIP Phone Mobile Home Space 25.00
i Commercial Back Flow Prevention Device or Antl- 25.00
Describe work New O Addition O Alteration O Repair Pollution Device
to be done: Residential 10 Non-residential O Residential Backflow Prevention Device' 15.00
Additional description of work. Any Trap or Waste Not Connected to a Fixture 9.00
Catch Basin - 9.00
I
J Jr y"UIC Insp,of Existing Plumbing 40.00
per/hr _
Existing use of Specially Requested Inspections 40.00
building or property_ _ erfhr
Rain Drain,single fam!;y dwelling 30.00
Proposed use of Grease Traps 9.G0
building or property
-� QUANTITY TOTAL 2 c�
r acknowledge that I have read this application,that the information Isomeft or riser diagram I.required s Ouanity rolal is >9 J
erect,that I am the owner or authorized agent of the owner,and - *SUBTOTAL _
ubmdted are in compliance with Oregon Slat Laws. `i
`
Owner/Agent i t` Date ,y p �" 6%SURCHARGE r �
a. iron Nettle Phone PLAN REVIEW 26%OF SUBTOTAL y
Rewired only if firtur� total Is_>9 _
TOTAL 1
'Mlnimum permit fee is E25, 5%surcharge,except Residential Backflow
Prevention Device,which is$15}5%surcharge
rloc .az
LE-C-Q PLE
Fixture Type Quantity by Work Performed
New Moved Replaced Removed/Capped
Sink —
Lavatory -
Tub or Tub/Shower Cornbination - -----
Shower Only - -- - -
Water Closet _ -
Dishwasher e - --- -- - -- -
G_arbage_Disposal --�-
Washing Machine --- - ---
FloorDrain---2" - --
4" -
Water Heater _ -- - -- ----
Laundry Room Tray --- - --
Urinal - -- -_ ---
Other Fixtures (Specify) ----
COMMENTS REGARDING ABOVE:
Lr
s,1 7a A-A"Mi-TABo L
SEPTIC SERVICE
P.O.Box 11:,o
WILSONVILLE,OR 970,'0
(503 682-1929 FAX(503) 670-0779
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