Permit .„
CITY OF TIGARD
PLUMBING PERMIT
° COMMUNITY DEVELOPMENT PERMIT #: PLM2009 - 00021
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/6/2009
PARCEL: 1 S136CC -02100
SITE ADDRESS: 11746 SW PACIFIC HWY ZONING: C - G
SUBDIVISION: DUTCH BROS. COFFEE LOT: JURISDICTION: TIG
PROJECT: DUTCH BROS. COFFEE
Project Description: Install (3) floor drains, (1) hose bibb, (1) grease trap, (1) primer, (4) sinks, (1) water closet, (1)
water heater, (1) backflow preventer, 120 ft. water service.
•
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: FLOOR DRAINS; 3 TRAPS:
STORIES: WATER HEATERS: 1 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 4 URINALS: GREASE TRAPS: 1
LAVATORIES: OTHER FIXTURES: 2
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: 120 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
GRUNBAUM FAMILY TRUST
21390 SW EDY RD Description Date Amount
SHERWOOD, OR 97140 [PLUMB] Permit Fee 2/6/2009 $347.00
[TAX] 12% State Surch 2/6/2009 $41.64
Phone : Total $388.64
Contractor:
JUDSONS INC
PO BOX 12669
SALEM, OR 97309 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 363 -4141
FAX 503 -583 -7894
•
Reg #: LIC 34604
PLM 24 -22pb
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: (� t � Permittee Signature: l\ (�ll)
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.
02/06/2009 10:14 5035847894 JUDSON'S INC. PAGE 01/03
i •
Plumbing Permit Applieati Er
Building Fixtures I IL LI V C 1.,,R ()HI. 1. i 1/4.I, WO 1
City of Tigard FEB 6 2009 Received ) • l o Oct • ' ,nit NM: P1-rn 2004 • 00 I
114 ' 13125 SW Hall Blvd., Tigard OR 97223 see Page 2 for
i plan Review ptherpermitNo.: I11I-L Q
Phone: 503.639.4171 Fax: 5 03s9�i} OF TIGARD natdar
Inspection Line: 503.639.4175 Dare Ready/By: Iuris. la
,, BUILDING 4. til Information
Internet www.tigand- or,gew DIMS nN >�+wl�arrae�oa
' . • OF WORK • $ 161 .:..
For special btformetren use chec
El New construction 0 Demolition Descri Lam, forol
0 Addition /alteration/replacement [] Other. New 1 2- family dwellings (includes 100 ft. for each utility connection)
• CATEGORY OF C0N'1'RIPGrION SFR (1) bath 249.20
0 1- and 2- family dwelling ® Comma cia1fmduslrial SFR. (2) bath 350.00
0 Accessory building 0 Multi- family
SFR (3) bath 399.00
Each additional bath/kitchen 45.00
0 Master builder ❑ Other: - Fire sprinkler L, sq. ft.) Page 2
• • JOB SITE 11VFtiiP.MATTON AND LOCATION Site utilities
Job site address: 1174i{ SW PACIFIC HWY _ Catch basin or area drain 16.60 ,
City /State/71P: TIGARD OR 97223 Dryweit, leach line, or trench drain 1 6.60
Suite/bldg./opt no.: I Project name: DUCH BROTHERS COFFEE Footing drain (no. linear ft.: �) 2 ,
Manufactured home utilities 1I0.00
Crow street/directions to job site: CROSS STREET IS SW DARTMOUTH ST
Manholes 16,60
Rain drain connector 1 6.60
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.:, ) Pagc 2
Subdivision: - 1 Lot no.: Water service (no. linear ft.: no 2 Page 2 LO k .2-‘0
- Fixture or Item
Tax map/parcel no.:
sorption valve i 6.60
BESC' ION OF WORK Bacicflow przventer 1 Pagc 2 L%f . 40
ROUGH -iN, TOP OUT AND SET FIXTURES. INSTALL AND TEST Backwater valve 16.60
BACKFLOW AND INSTALL. WATER SERVICE Clothes washer 16.60
Dishwasher 16.60
• 0 PROPERTY OWNER .. L 0 TEN - ANT Drinking fountain 16.60
Ejector: /sump 16.60
Name: Expansion tank 16.60
Address: Fixture/sewer cap 16,60
City /State/ZiP: Floor drain/floor sink/hub ' 3 16.60 49.80
Phone: ( ) Fax: ( ) Garbage disposal 16,60
Hose bib 1 16.60 1 6.6
ig APPPLiCAN'1C ' 0 CONTACT PERSON Ice maker 16.60
Business name: SAME AS BELOW interceptor /gtease trap 1, 16.60 16.60
Contact name: Medical gas (value: $ ) Page 2 '
Address: Primer 1 16.60 16.60
Roof drain (commercial) 16.60
City /State2lP: _Sink/basin/lavatory 4 16.60 66.40
Phone: ( ) t Fax: : ( )
Tuh /shower /shower pan 16.60
E -mail: sfnwler@judsousplumbing.cnan urinal 16.60
. CONTRACTOR _ Water closet • 1 16.60 16.60
Business name: JUDSON'S INC. Water heater 1 16.60 16.60
Address: PO BOX 12669 Other:
Subtotal 347.00
City /State/7TP: SALEM OR 97309
Minimum permit f1e: $72.50
Phone: (503) 363 -4141. Fax: (503) 583 -7894 Rmidential backflow minimum permit fee: $3625
CCB Lic.; 34604 Iy • Ito. 1 k Plumbing Lic. no.: 24-22 PR t Plan review (25% of permit .fa)
1 State surcharge (12% of permit fee) 41.64
Authorized signature:
%.34c TOTAL PERMIT FEE 1 388.64
Print name: SUSAN FOWLER - JUDSON'S INC. -I Date: 2/6/09 This permit application expires If a permit is net obtained within
180 days after it has been accepted as complete.
SO 0 5 1 5 6 9 3 *Foe methodology set by Tri- County Building industry Service Board.
CITY OF TIGARD " ' 1
: A BUILDING DIVISION PERMIT #: PI-M2009-00021
13125 SW Hall Blvd., Tigard, OR 97223 0 U �� DATE SUED: 2/t'�f: Q )9
Phone: (503) 639 - 4171 Val' " v � ` Inspection Rquests (24 Hrs.): (503) 639 -4175 O / ��
INSPECTION WORKSHEET FOR DATE: 2J 13/2009 TIME: 7:OOAM PAGE: 11
SITE ADDRESS: 11 746 SW PACIFIC HWY CLASS OF WORK:
SUBDIVISION: DUTCH BRR7OS. COFFEE LOT #: TYPE OF USE:
PROJECT NAME: DUTCH BROS. COFFEE
DESCRIPTION: Install (3) floor drains, (1) hose bibb, (1) grease trap, (1) primer, (4) :inks, (1 w closet, (1) water heater, (1) backflow preventer, 120 ft. water service. '32 )4:5 _ q �rr'
OWNER: GRUNI3AUM FAMILY TRUST, PHONE #: J
CONTRACTOR: JUDSQNS INC ifrig PHONE #: &13 363 - 4141
Inspection Request Scheduled For: Date: 2/13/2003 ■ ,
Ins " Pour Time:
P q J
Code # Inspection Description Confirm # Contact # Me sa e
305 Plumbing undetsIab 0005:28-01 503-363-4141 Y
Corrections /Comments /Instr cti
37) k. ons:
• g; ❑ PARTIAL APPROVAL El CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: a/1 --5/0 Phone #: (503) 718?
■
• ,, , 809729
❑ NEW '
°EXISTING
PNWS -AWWA BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
II r ❑ REPLACEMENT
OWNER:
PROPERTY I : i C Ci _fey., �» t t f r r, I f PHONE:
MAILING
ADDRFSS:
CITY STATE ZIP
ASSEMBLY _ Uf
p q { (, f
ADDRESS: / 1 ����' C � / �' % %� c
STREET .1
❑R.P.B.A. 041.C.V.A ❑ R.P.D.A. l 0D.C.I.A. ❑P.V.B.A ❑S.V.B.A. ❑AV.B. ❑AIR GAP
SIZE: 1 111.1DI C) MAKE: L4/ rr S MODEL:O0 1 6 T
WATER r C ` 7 / SERIAL `" ; --°7 ? 0) PURVEYOR: L c ( r ; C i r '.'' C-' NUMBER: /
ASSEMBLY / �
LOCATION !i��LA Jam ^ 1t'�' , �
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL T�E� ST
�
M CHECK IOU'BBLE,"CHECK IJ "- AIR CHECK PASSED
! PRESS DROP (A) CHECK #1 INLET FAILED ❑
INITIAL RELIEF VALVE r
$ (TIGHTy� ) et OPENED AT. PRESS DROP
OPENED AT '" DATE:
TE$T MIN 2 PSIp PSID . 1 / - r / ; J !!
B= I CHECK N2 •
' RESULTS (LEAKED ❑
BUFFER PSID PSID
A -
MIN 3 PSI IX ` 6 DID NOT FAILED SYSTEM
RELIEF VALVE
PASS ❑ FAIL ❑ LEAKED �D OPEN ❑ ❑ • PS[
.
COMMENTS
REPAIRS
AND /OR
PARTS
-
m REDUCED PRESSURE ASSEMBLY P .V.B.A /S. V. B.A. A REPAIRS
/I CHECK
PRESS DROP (A) ^ °.° DATE:
CHECK #1 TEST • RELIEF OPENED AT PRESS DROP
AFTER OPENED (B) I 1 T IGHT ❑ PSID / /
REPAIRS BUFFER WOULD 1 CHECK #2
A -B- PASSED CI 10 (TIGHT ❑ PSID PSID PSID ,
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRAT -D'A E' � / DETECTOR METER READING �I/.
TESTER SIGNATURE ,-'-.- / / d 75"
- l 0 ,°cN e - x.A . d tai
TESTERS NAME PRINTED ? C ., t': ,. 1.-__ {- f GAUGE N . ( f l. ;
TESTERS ADDRESS -- / % PHONE 0
. a� -»- f C .
COMPANY NAME
DSERVICE RESTORED
REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER)
WHITE - Water System Copy PINK • Customer Copy YELLOW - Tester Copy