Permit �: • •
A • 640303
• ® NEW
PN W S -AW W A XISTING
BACKFLOW ASSEMBLY TESTREPORT ❑ REMOVED
PROPERTY 11. l ❑ REPLACEMENT
OWNER: 1 71e / PI A A VII . PHONE: NA
MAILING " ADDRESS: :20 �" S p/ 0 e Nr,a/K S f (Or)
CITY / /4 a /"Li , STATE eK ZIP 9722/
2Z
ASSEMBLY 1. 4
ADDRESS:
STREET
❑ R.P.B.A. T D.C.V.A. ❑ R.P.D.A. ❑ D.C.D.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V:B. ❑ AIR GAP
SIZE: I 1, 14461 MAKE: / U/a 7`, MODEL: _ 1/ 7 O h l .
WATER -r , PURVEYOR: / 1# a l^GJ NUMBER: 3 D u IS I J
LOCATION: � II l c1 //.l) — h e' r Cu
LOCATION: e a r h't / �• L D h
•
REDUCED PRESSURE ASSEMBLY • P.V.B.A. / S.V.B.A. INITIAL T ST
• NI CHECK • I'DOUBLE CHECK AIR CHECK • PASSED
PRESS DROP (A)I CHECK #1 INLET • FAILED ❑
INITIAL S OPENED ATVE (B)ITIGFIT P2 o / OPENED AT: PRESS DROP
DATE:
_- .. RESULTS MIN 2 PSID (LEAKED ❑ PSID PSID PSID ‘ //5/ 65
BUFFER - - ----- -
A - B= I CHECK #2
MIN 3 PSI
• RELIEF VALVE ' ITIGHT . DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ !LEAKEDD PSID OPEN ❑ PSI
COMMENTS
REPAIRS
AND /OR
PARTS •
REDUCED PRESSURE ASSEMBLY P.V.B.A. /S.V.B.A. AFTER REPAI
#1 CHECK . D.0 V.A. -
TEST PRESS DROP (A) I CHECK 41 DATE:
RELIEF I OPENED AT PRESS DROP
AFTER OPENED (B) TIGHT ❑ PSID
REPAIRS BUFFER `�' °� I •CHECK #2
A - R P SID ' PAS SED
.m,e°s I TIGHT ❑ PSID PSID // y
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE r
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE W(IT'T ALL APPLICABLE D
RULES AN_ REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS. k .
GE C,g>;LI N DATE '� D ETECTOR METER READING - J
fJ'ly � ,o ,mac.__ 33��I
� P ng e R'�"
R&,, E51N x /5' N II bo ow /z3 423- E
U A `; ck e� lokr F /o In s,D 32 , L,,,,pm S'
∎.. COMPANY NAME V
Y
'<SERVICE dSTORED
REPORT RECEIVED BY. (REPRESENTATIVE OF OWNER)
(
WHITE - Water System Copy PINK - Customer Copy - YELLOW - Tester Copy •
CITY TIGARD PLUMBING PERMIT
ik DEVELOPMENT SERVICES PERMIT #: PLM2005 - 00258
�� I "'1 DATE ISSUED: 6/14/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 25111 AC -00100
SITE ADDRESS: 09075 SW PINEBROOK ST ZONING: R -4.5
SUBDIVISION: PINEBROOK TERRACE LOT: 042 JURISDICTION: TIG
Project Description: Installation of backflow device.
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
KITTELSON, WAYNE K AND Description Date Amount
JANICE R
9075 SW PINEBROOK [PLUMB] Permit Fee 6/14/2005 $36.25
TIGARD, OR 97224 [TAX] 8% State Surcha 6/14/2005 $2.90
Phone : 503- 639 -8568 Total $39.15
Contractor:
R D PLUMBING INC
13900 NW SPRINGVILLE RD
PORTLAND, OR 97229 REQUIRED ITEMS AND REPORTS
Phone : 503- 297 -7422
Reg #: LIC 73913
PLM 26 -313pb
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
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 or 1- 800 - 332 -2344.
Issued By: o = Permittee Signature:, T
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
JUN - 14 - 05 TUE 8:38 AM R, D, P 1 umb i ng, Inc. FAX NO, 503 297 7344 P. 2
•
•
' . Plumbing Permit Application , , l I t-
FOR OF f ic US ONx,: . h, , , -, �,,
, .' 5 t h 4;° "ns
City of Tigard
RFC- >:ccc„Ti ,(
Ni 25 SW Wall Blvd., l'igard 7 ?� ��� D:,IC'13:6 7 –di— IrLtullf Nn M ', �� 9�
Phone: 503.639.4171 Pax: , 0_ ..V. 1960 _.-1------__ ..... ... . .. . .�> _y!`trs� E
24- } lour Inspection I„inc: 5O3. 539,417< + I)a1e Rc Odor PQfm,l No,:
ntct: wwwci.tigard.or.us 11 ,,, 1 1.� 20 4 "•� 'I?c
fnte Ual¢ Rct(Iv /Ay: l„
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ILA, �t� Noliric(IiMCthcd: i _.� 1 / e `wc 1 at;c = fi,�... _.
— TYrr, - � 1'( F14B0 J LL�.II 1r,J;;Atcn,rgrutilo,1^,:attun_ �.
l �� 11(!:" scir ;I)t'1,E
0 NOV oonstruclion - - -� � cmoiitiu :t -- __..:..... - • „__.•- ,.-- ---•__ _
DI %rrr.t�lt cr rr %i irlr , nn , rlir , rr n.,tt <lrr'r d'Ir.,r,
Q Addition/alteration/replacement Ulhc Description ""T' 1 `-'r-.T.:1---- ; ro _,_, -.
\p„ 1- 2- lantih (Itvelliwgr. Inn 0 lilt' p:,t it tilii,l t 4:01111 it
CATIsGORIr Or CONSTRUCTION — �_ - • -- - � _._... „_ -- .., •. n:.
Q I• and 2- family dwelling . 1.•
C' »crc /i ndustri,,l Slit (?I hail, 1 ;; t r in
r
L] Accessory building
_ [1 Multi-ran-10y
SFR (31 hall
❑ MaSler builder Each i,dditian „I both/kitchen n
❑ Other: a (k, • I
Fire sprinkler 1
JOB SITE, INFORMATION AND LOCATION
i......_.,...
q Site ulililicc
A �./j i _ / Catch basin or area dram I i, (tu i
City /Slate/7IP: 4+ 4 1 I)r\„cll, leach rm. or IrCnc:h dr;im I
Suitc;/hldg ✓apt. nn.: Project name: I - ' Fonttri dram (nn, linear IL: t t i _..
ttt a M% ! $ P11' :,.• 1
Cross slrccVdircelintIS to job site: l`rlatwlucturc(I home utilities � � — I I( (I, -i ' --__
i - Manholes I (
.�__�.
Rain drain connector _ 1t >.tif), �
w —_- Sanitary' sewer (no, linear R„ _�} IV 1 , 1
Storm sew (no. linear 11.: r - ,__., •..,. -_-
SUhdivisi0,t: Water service no. linear /Page -'`,.__._.._,.. -,..
1,c4. no.:
( 1
Tax map/parcel no.:
FiNture or item
- _._.. Absog,uvn valor 1
DESCRIPTION 01 WORK
_ . (, ;
' --' Back 1101 PrrvC,ltcr } _ ' f , r _ —
Back, \titer ,'idol: w__ _. . -__ w. L,f..,� _ (.t,.
i (,(,11 t.
Clothes washer i - -.,
Dishwasher
~
0 PROPERTY OWNER Drinl ing Count :tin _ r - _.. �
— ❑ TENANT - ..- _- _.,. ____ -• .!_._ fi,
�' I :lectors /sum) - - f - -_
Name: • .1;21,0 1�-- V I -- ^..� ---- -- j..,,.. 1 1, n„
�- Expansion look -- -
- 1(, r,( l
Address; -- ..._.,,. - ...- .-...._...__
Fixture/sewer cap 1 b s a
City /State/llP:
Floor chain /flour sink /foul .... -
��� � .._. l {,.toil • .,......
Phone: ( (3 / ? ��� Fax' ( ) ~ Garbage dispt�a,l Il: i,tl
0 APPLICANT ❑ CONTACT PERSON !lose bill t I(,.(,n 4 ...._ ..............
Eiusl nano: lei maker - .._ _ _,�,.... - n. - t ,,,, „ -
. - - - -- lh . t• L1 1
h / grease (rap ^ I LL I n Gig t
Contact name: _..._ -.. ._.._.•...._.__.
_- „_..-- Medical gns t\ aloe: ) ';'L'
A ddresS: 1-
Primer
City/State/ZIP: RuQI (Irwin lcnntq)crcisdl - -- _..__t ~.� -. --- -• ,. (6.60 _.._- _...._.__ •
— I rode: ( ) r:,s:: ( } Sink /htuin /li,valuf) }h C
-
-
1 nh/shn„er /Shu min
n j.....i f, r >u .J,..:_ -,..-I
1
..�. � , - Urinal h 1 r, r•'.;
CON' MRACTOR
_ _____ --� \VHlcr closet JO 1111 .�. .,.,...._._.. - •
rU� (44 0 I n Water hct .�_'. ..
Address' L0 — _�. Olhr, -., I_�, . ,..
r cityistaidzir: Yt r / /l n .1.9 ..� •----- - - - - -- .,.
1 Phone; ( ) mini ,,,,,,,,,„ 1 s'7�. 1, i
_ �] 1'd \; ) ^ n , l ftl I ii Ili%: l�iC,�i
L� 2 9''1 7- L _ t.,,,,,,I., ,,,,,....1.,,,, „n,a„ i ,crtn I
L&13 L,ic.: `"L Plumbing Lie. no, .,, e.:... , 1 3 , r � /17 -- - flan review (2;"(,uf , . _.__....,.. _
Authorized siFnauz: State surcharge (Rm of permit Ic
\ ___ ___ I(,1,,I,I'I•It 1 -?•I j` - J
Print name.; a N 9 0 0, S ( Date: f _ V -/ (i -07i I •1'Itis perm app a %p es i pertt, i t n(,f nlrfa wit Iii
~
u � !J 1$O d},cs After i1 11 as hrcn at•L' t1I'd :t4 e■wl,ltic,
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n„: gtinglPern ,hs,rrn +- Permi,np +p dnc 1 !n, lee ntethnduluc, . l h; '1 •rl-('l,unn fiinIchn,' imh,i,,. tir iln.inf
4 J0.4 , 1167 1 0/n r'pt 1
CITY OF TIGARD
BUILDING DIVISION , ,PERMIT #: PLM2005 -00168
13125 SW Hall Blvd., Tigard, OR 97223 -D FE ISSUED: 6/14/2005
Phone: (503) 639 -4171 . � 1 d � M4,
I Requests (24 Hrs.): (503) 639 -4175 � «R__ / 3
INSPECTION WORKSHEET FOR DATE: 6/15/2006 TIME: 7:16AM PAGE: 91
SITE ADDRESS: 09075 SW PINEBROOK ST CLASS OF WORK:
SUBDIVISION: PINEBROOK TERRACE LOT #: 042 TYPE OF USE:
PROJECT NAME: KITTELSON
DESCRIPTION: installation of backflow device.
OWNER: KITTELSON, WAYNE K AND, PHONE #: 503 - 639.8568
CONTRACTOR: R D PLUMBING INC PHONE #: 503 -297 -7422
Inspection Request Scheduled For: Date: 6/16/2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
326 RP /backflow preventer 009317 -01 503 -297 -7422 N
Corrections /Comments/ Instructions:
I k
( .
0 ,
SS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: ` v\ O v Date: 6 / C / A Phone #: (503) 718-