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Permit CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit #: PLM2009 -00102 TiGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/28/2009 Parcel: 2S103AD07700 Jurisdiction: Site address: 12676 SW 108TH TERR Subdivision: MILESBROOK Lot: 8 Project: MILESBROOK Project Description: Install backflow preventer for new SF. Owner: FEES BUENA VISTA CUSTOM HOMES INC Quantity Description Date Amount 5665 SW MEADOWS RD #150 1 ea Backflow Prevention - RES 04/28/2009 $27.55 LAKE OSWEGO, OR 97035 1 12% State Surcharge - 04/28/2009 $4.35 PHONE: Plumbing 9 ea Minimum Fee Adjustment 04/28/2009 $8.70 Contractor: - Plumbing ROSS ELECTRIC INC 2870 SE 75TH AVE #203 HILLSBORO, OR 97123 PHONE: 503 -642 -2800 FAX: 503- 642 -5815 Type of Use: SF Class of Work: NEW Type of Const: Occupancy Grp: Stories: Total $40.60 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules Issued By: (. 4 livn � Permittee Signature: ) 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. F Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard dteceived r� Permit No. III • 13125 SW Hall Blvd., Tigard, DateBy: C OR 97223 � . PS ( Pr! Vhf • 00102. ■ Phone: 503.639.4171 Fax: 503.598.1960 APR 2 8 2009 Date/By: Other Permit No.n/i ° ��-l2 Inspection Line: 503.639.4175 ! T A �1 Date Ready /B T 1 G uris 0 See Pa 2 for N l� R D Internet: www.tigard- or.gov CITY E i N V Notified/Method: j� Supplemental Inform ation TYPE OF WORK BUILUNU UIVIbIUN FEE* SCHEDULE ®J'1ew construction ❑ Demolition For special information use checklist, Description I Qty. Ea. Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 ❑ 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 Each additional bath/kitchen 45.00 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: I24-0,-4 c`X.A...) 1 o p 1Lt r LL � ra „ Catch basin or area drain 16.60 City /State /ZIP: et U f 1 7 Z1 a Drywell, leach line, or trench drain 16.60 Suite/bldg./apt. no.: Project name: 1 Footing drain (no. linear ft.: ) Page 2 64 lltb (d Y eon Manufactured home utilities 110.00 Cross street/directions to job site: 1lN VI .c. 1 - Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Water service (no. linear ft.: ) Page 2 Subdivision: 1 l os q r01*JK I Lot no.: cg Fixture or item Tax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK CBackflow preventeiTh Page 2 Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 a- PROPERTY OWNER , ❑ TENANT Drinking fountain 16.60 Ejectors /sump 16.60 Name: 8 0 . Inch v I I f' 0 VN_•`a Expansion tank 16.60 Address: _ _ . A a _� Fixture /sewer cap 16.60 City /State /ZIP: I Floor drain/floor sink/hub 16.60 Phone: (ems) � to 0 21ei _ Fax: ( ) Garbage disposal 16.60 ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60 Ice maker 16.60 Business name: go. rAricA. ,v 4 0, { 0 ..AA...A_ ` Interceptor /grease trap 16.60 Contact name: 1r) 5 cow" 2 1 ,�, ( e. T - Medical gas (value: $ ) Page 2 Address: J ? l ex v � I _, k--, . 'SC O @, . Primer 16.60 City /State /ZIP: 1�� Roof drain (commercial) 16.60 Phone: (f5' -7 Fax: : ( ) Sink/basin/lavatory 16.60 [ Z 1 1 • Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name: Water heater 16.60 Address: Other: City /State /ZIP: Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (12% of permit fee) Authorized signature: rf� TOTAL PERMIT FEE `� V , t Print name: Date: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. 1:\ Building \Permits\PLMF- PermitApp.doe 12/27/06 440- 4616T(10 /02 /COM/WEB) 4 ' Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - ls` 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 7,200 $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 Systems: 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 Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and 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 is ential Backflow Prevention Device each additional $100.00 or fraction thereof, to .1 permit fee $36.25 - 27.55 and including $25,000.00. Rain Drain, single amity 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 fraction thereof, to Inspection of existing plumbing or and including $50,000.00. specially requested inspections - per hour 72.50 Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for each additional $100.00 or fraction thereof. Commercial Fixture Work: Plan Review for Plumbing Installations Are you capping, adding or replacing fixtures? If "yes", Plan review is required for any of the following. please indicate work performed by fixture. Failure to Please check all that apply. accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed Fixture Type: Replace engineer. Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure Baptistry/Font as defined in OAR918- 780 -0040. Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. -Drive Thru Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial - Domestic Drinking Fountain Isometric or Riser Diagram Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain/sink - 2" that meet the qualifications above. -4" Car Wash Drain Garbage -Domestic Comments regarding fixture work: Disposal - Commercial - Industrial Ice Mach. /Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - Toilet Urinal Other Fixtures: isBuilding \Permits\PLM- PermitApp.doc 12/27/06 PL , W 34902 4I NEW BACKFLOW ASSEMBLY. TEST REPORT ❑ ❑ REMOVED TING PROPERTY I 11 REPLACEMENT OWNER: r 1 v e hi & V 1 5 74 - 1-) 0 W e PHONE ADDRESS: - ( n ( S w M ea.A r,u./ 0 12. , • • CITY a. l< C G 5 uJ. es o STATE.. G /2 ZIP / 7 O 3 S ASSEMBLY v . ADDRESS: 12 , 7( 5 w 1 o ZS _ 1 e - 1' " ne t e . cI o 2, 9 7 STREET v El 'R.P.B © :A. 'D.C.V.A. ❑ R.P:D.A. ❑ D.C.D.A..❑ P.V.BA. ❑ S.V:B.A. ❑ A.V.B. ❑ AIR GAP. SIZE: I }i' CA; 0) MAKE: . /4- cerbc -/(4 MODEL 49' 1"r ,' ( )."- WATER SERIAL � `,, J q PURVEYOR: 1 I `i Ir A NUMBER: / -1. C o` 4 1, ASSEMBLY , , (n� v i LOCATION: 1$l.#C J 551nT,+� f d �t '' .v � ( ., .cG J . 8 e /G cc, [,. / 0,./e, .v.../ - • .REDUCED: PRESSURE ASSEMBLY P.Y.B:A. /'S.V.B.A. INITIAL TEST #1 -CHECK I DOUBLE CHECK AIR CHECK PASSED ICJ" PRESS DROP; (A ) • } CHECK #1. INLET FAILED ❑ ' RELIEF, VALVE INITIAL OPENER AT , (B) TIGHT E] �9 . 7 OPENED AT: PRESS DROP TEST 'MIN PSID •. • DATE: BUFFER LEAKED ❑ PSID RESULTS .' MIN 3 PSI CHECK #2 PSID PSID y / 2 9 /0 f RELIEF VALVE TIGHT fr . 2 , S DID. NOT FAILED SYSTEM g ' PASS ❑ FAIL : ❑. LEAKED 111 PSID OPEN ❑ El PSI'' F • COMMENTS REPAIRS . AND / OR PARTS - • REDUCED,PRESSURE'ASSEMBLY #I_CFIECK P:u P.V.B.A. /' S. AFTER REPAIRS • D . C .V.A TEST PRESS DROP ( A) I DATE: , AFTER RELIEF CHECK #I OPENED AT PRESS DROP REPAIRS OPENED (B) TIGHT ❑ PSID / / MIN .2 PSID BUFFER CHECK # 2 ' A .- 13 = TIGHT ❑ PSID PSID PSID PASSED ❑ MIN 3 PSI ' IN COMPLETEINC AND SUBMFI 1'1NG; PHIS TEST REPORT, THE TESTER CERTIIIES THAT THE ASSEMBLY HAS . BUN TESTED, AND 'MAINTAINEDIN ACCORDANCE WITH ALL APPLICABLE. . • ' - RULES AND REGULATIONS OF THE WAT 'SYSTEM, AND STATE; REGULATIONS. GAUGE CALIBRATION 4/ 7 /Q ' DE /FOR METER ING ✓/l fitllf - , ((�G TESTER SIGNATURE CERT # • Randy L. Davis 4289 . TESTERS NAME PRINTED 212 SE 3rd St. 020486 GAUGE ,# TESTERS ADDRESS _ t , a " • 1 . 1 1 -, • i 1 G PHONE# . rou., a e _ COMPANY. NAME JI = u, , ' :: - - ' " . g WWW.WATERMETRICS.COM SERVICE RESTORED,. , REPORTRECEIVEDBY. (REPRESENTATIVE OF OWNER) WHITE - WATER SYSTEM COPY PINK - CUSTOMER COPY . YELLOW - TESTER COPY