Permit CITY OF TIGARD
PLUMBING PERMIT
Pe r_ . DEVELOPMENT SERVICES PERMIT #: PLM1999 -00393
13125 SW Hall Blvd., Tigard, OR 97223 (503)639 -4171 DATE ISSUED: 11/22/1999
. SITE ADDRESS: 11585 SW 67TH AVE PARCEL: 1 S136DD -00800
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 003 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: UNK 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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: installing sewer line and disconnecting from existing septic tank.
FEES
Owner:
Type By Date Amount Receipt
FAMILY BAPTIST CHURCH PRMT BON 11/22/1990 $50.00 99- 319952
11585 SW 67TH 5PCT BON 11/22/199£ $4.00 99- 319952
TIGARD, OR 97223
Total $54.00
Phone 1:
Contractor:
CANTRELL & SONS CONTRACTING
6860 SW NORSE HALL RD
TUALATIN, OR 97062 REQUIRED INSPECTIONS
Phone 1: 503 - 638 -0800 Sewer Inspection
Reg Final Inspection
eg #: LIC 97005
oRIGINAL
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 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued By: - AA//W d ( Nl^ Permittee Signature: , 6 / / /, /,
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
•
CITY OF TIGARD Plumbing Permit Application Plan Check#
13125 SW HALL BLVD. Commercial and Residential Rec'd By l I l L "I . 6 1
TIGARD, OR 97223 Date Recd
(503) 639 -4171 Date to P.E.
Print or Type Date to DST Permit # PLM ('P '' ' 4 `3
Incomplete or illegible applications will not be accepted Related SWR ea, ` ( ` r.
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
Job Sirs' 11.50
Address tree ddre s lo � Suite Lavatory 11.50
Tub or Tub /Shower Comb. 11.50
BIdg .CiFtate p � /f ZipQ Shower Only 11.50
Ti 'w 0 e. " �IA . WaterCloset/Urinal (Specify) 11.50
fl!' �, � y„t i I l �7 s I / V I U R Dishwasher 11.50
Owner Mailigg Addrfiss Suite Urinal 11.50
/ /1153.6 c - & .697 Garbage Disposal 11.50
Qty/State Zi Phone
T/
�r q n.3 Laundry Tray 11.50
W te 1rz d R. y ' / o(or
e Washing Machine /Laundry Tray (Specify) 11.50
Floor Drain/Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" 11.50
4" 11.50
City/State Zip Phone
Water Heater O conversion O like kind 11.50
Nxne Gas piping requires a separate mechanical permit.
oeNe >; - 0/ / A ilk > !I MFG Home N Water Service 28.00
Contractor /pAa Address I (�, Suite MFG Home New San/Storm Sewer 28.00
� D 50 I PoRie I P f Hose Bibs 11.50
Prior to permit Ci Statf �; Zi Phone Roof Drains -.. 11.50
issuance, a copy 1 (la t 7 R _ oY -636 ;P30 Drinking Fountain 11.50
of all
fired i are Orego' 9 904ont_Board Lic.# ExP• iegi �b1S /G'D Other Fixtures (Specify) 15.00
reired if Y''JI � o ff) `
expired in COT Plumbing Lic. # Ex . Date
database
Name
Architect Sewer - 1st 100' / 38.00 .r10
Or Mailing Address Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00
Engineer City /State Zip Phone Water Service - each additional 200' 32.00
Describe work to be done: Storm & Rain Drain -1st 100' 38.00
New O Repair O Replace with like kind: Yes O No O Storm & Rain Drain - each additional 100' 32.00
Residential O Commercial O
Additional description of work: Commercial Back Flow Prevention Device 32.00
Residential Backflow Prevention Device" 19.00
7l ^ (P-t �' Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes O No O Inspections per/hr
If yes, see back of form to indicate work performed by Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES. QUANTITY TOTAL
1 hereby acknowledge that I have read this application, that the information Isometric or riser diagram is required it Quantity Total is > 9
given is correct, that I am the owner or authorized agent of the owner, and -
that plans submitted are in compliance with Oregon State Laws. SUBTOTAL
Si nal rd of Ow er /A nt 11 Date p
1/41.1 why �hrf 1,! , US( )).)7%q 1 8% SURCHARGE tl s) 0
Contact Perso ame y a v Phone
'"`PLAN REVIEW 25% OF SUBTOTAL
1 BATH HOUSE 5178.00 Required only if fixture qty. total is > 9
2 BATH HOUSE $250.00 TOTAL D(
'S BATH HOUSE $285.00 ! -
t (This fee includes all plumbing fixtures in the dwelling and the first •Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Prevention
' 100 feet of sanitary sewer storm sewer and water service) _ _ _ _ j Device, which is $25 + 8% surcharge
n � Q l C�fJ' All New Commercial Buildings require plans with isometric or riser diagram and
�X �C
plan review.
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PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved I Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Urinal
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
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