Permit CITY Ti PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2008 - 00289
TtGnRD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 7/8/2008
g PARCEL: 2S103BD -06300
ia�S3
SITE ADDRESS: 1.648 SW 116TH AVE ZONING: R -4.5
SUBDIVISION: HUNTER'S GLEN LOT: 019 JURISDICTION: TIG
PROJECT: LE
Project Description: Installing backflow preventer.
CLASS OF WORK: ALT 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
PATRICIA LE
1.2 4& SW 116TH AV Description Date Amount
2453 TIGAR OR 97223 [PLUMB] Permit Fee 7/8/2008 $36.25
[TAX] 12% State Surch 7/8/2008 $4.35
Phone : Total $40.60
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # : PRI
Reg #:
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: 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.
Plumbing Permit Application I*
Building Fixtures ` ! ' ' f , y , , .,:::e144,,,,,: , ,a 'F,94 °N ; '' . ����F ' �
"I'iF''� ° "' Received
t 4, r, City of Tigard ; cp.) 7 c ermit No.: Q
I II " 13 !25 SW Hall Blvd., Tigard, OR ::5� a�0 DateBy: ( 0 6 J/ p (�U�T.�
* ' D Ptan Rev iew
� Phone: 503.639.4171 Fax: 503.5'8.1960 0 ... o p ® ateB Other Permit No.:
•rm∎mik ! Inspection Line: 503.639.4175 CIr ` to Read /B ® S ee Page `� \,i Ready /By: B
tai Internet: www.tigard or.gov _ 1 O% -• _, ■ Notified/Method e 2 for Supplemental Information
TYPE OF WORK G � �� , '. FEE* SCHEDULE
El New construction ❑ l+rliiion For special information use checklist
Description 1 Qty. 1 Ea. 1 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
,c[ 1 �.fE INFORMATION AND LOCATION Site utilities
Job site address: ( l � '2,� t1 6 f .,0 1 Nolit PVbE Catch basin or area drain 16.60
City /State /ZIP: 1 1(.7ft.F) ) C('7' Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: _) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK . Backflow preventer / Page 2 • (p ,e
&Ci ` r 004) Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ , PROPERTY OWNER I Drinking fountain 16.60
❑ TENANT
Ejectors /sump 16.60
Name: p
/� �
Expansion tank 16.60
Address: 1r s3 '-cup t �t 2 �1 Fixture /sewer cap 16.60
City /State /ZIP: T i(.gIRI-D , 9 "1 - Floor drain/floor sink/hub 16.60
' Phone: (5 5.-73 1 ( Fax: ( ) Garbage disposal 16.60
❑ "APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: S �
,./1 -� of Interceptor / trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR . ' • Water closet 16.60
Business name: c4,tiVe 7 Water heater 16.60
Address: Other:
Subtotal
City /State /ZIP: Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 4 54 ,as
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) 4 3S
Authorized signature:( PERMIT FEE IV 6-() Print name: f ( c. A ( Date: -- 7 f �' 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.doc 12/27/06 440- 7616T(10 /02 /COM/WEB)
Plumbing Permit Application - City of Tigard •
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site' Utilities' . Qty. Fee (ea) Total S Footae• Permit Fee: Square g.
Footing drain - 1 100' 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
Fee (ea) Total additional $100.00 or fraction thereof, to and
I� ixture Or;Item Qty. 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 Backflow Prevention Device 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 for
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50,001 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
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
engineer.
Fixture Type: Replace g
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.
-3 „
-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:
i.\Building\Permits\PLM- PermitApp.doc 12/27/06
•
Information Notice to Property Owners About
Construction Responsibilities Statement
Oregon Law requires residential construction permit applicants who are not licensed
with the Construction Contractors Board to sign the following statement before a
building permit can be issued. [ORS 701.055 (4)]
This statement is required for residential building, electrical, mechanical and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7), need
not submit this statement. This statement will be filed with the permit.
Please check the appropriate box and complete the following statement:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will instruct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
y I will be performing work on property I own, a residence that I reside in or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If 1 change my mind and hire a general contractor, I will contract with a
contractor who is licensed with the CCB and will immediately notify the office issuing this building
permit of the name of the contractor.
I have read and understand the Information Notice to Property Owners about Construction
Responsibilities contained on these two pages and I hereby certify that the information checked and
completed above is correct and accurate.
V� A- Le
Print name of permit applicant Signature of permit applicant
Date
Permit #: / CS"03at$i
This form is supplied to building lo�Gy�s //� Arr.
permit offices by the Oregon Address:
Construction Contractors Board, "' kr* . q
as required by ORS 701.055 (6) . '..a , T' '� �� ( 3
- Z 7 ®�r
Issued by: Date:
This copy to issuing permit office
CITY OF TIGARD : -
BUILDING DIVISION PERMIT ; . 1 kM200B.00289
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED` 1/8/2008
Phone: (503) 639-4171
Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 7/11/2008 TIME: 7:00AM PAGE: 9
x6 S3
SITE ADDRESS: :f-} SW 11TH AVE CLASS OF WORK:
SUBDIVISION: HUNTER'S S GLEN LOT #: 019 TYPE OF USE:
PROJECT NAME: I E
DESCRIPTION: Installing backflw preventor.
OWNER: L..E, PATRICIA PHONE #:
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 7611/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
399 Plumbing final 072533 01 503.6247316 N
Corrections /Comments /Instructions:
- re c Co 1 9 C) tee-F-0,71'
A-1 I7 b S
61 /‘ De 0 1- AA vt co ort 4
L2 53 St.) t 1G -
n PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: _ / 1 1 1.0 Phone #: (503) 718-