Permit CITY TIGARD PLUMBING PERMIT
a �r� y � A DEVELOPMENT SERVICES PERMIT #: PLM2001 -00249
AO „� II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 06/14/2001
SITE ADDRESS: 12465 SW 72ND AVE PARCEL: 2S101A6 -01900
SUBDIVISION: HERMOSO PARK ZONING: MUE
BLOCK: LOT: 015 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
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: 20 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install of new water service (20').
FEES
Owner:
Type By Date Amount Receipt
GARY WOOD PRMT CTR 06/14/2001 $72.50 27200100000
12465 SW 72ND AVE 5PCT CTR 06/14/2001 $5.80 27200100000
TIGARD, OR 97223
Total $78.30
Phone 1: 503 - 968 -9200
Contractor:
ANCTIL PLUMBING INC
16900 SW MERLO RD
BEAVERTON, OR 97008 REQUIRED INSPECTIONS
Phone 1: 503 - 642 -7323 Water Service Insp
Reg #: LIC 24184 Final Inspection
PLM 26 -162PB
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: 4 � ,%/4,j i ta� Per mittee Signature: Ap/ / d / 1l. A , Ai'
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
4,,,
Plumbing Permit Applica on
. • Date received:& / T / ) Permit no.`. e(&D (: (02
r..rp. ;i, City of Tigard !�� « , -,,, - -) '
.-11- ;� 1 1. `J g Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 - Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: I Receipt no.:
Land use approval: C0- : • • III , :, Case file no.: Payment type: .
TYPE OF 1' :12MIT
O 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration/replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: /7__41 5‘..1 7 Z 4._ Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax ma /tax lot/account no.: (includes 100 ft. for eachutility connection)
P SFR (1) bath
Lot: Block: I Subdivision: SFR (2) bath
Project name: C.2 w i , ei A SFR (3) bath
City /county: 71 I ZIP: 9- 220 Each additional bath/kitchen
Description and lodation of work on premises: Site utilities:
R - tf,.. i...4_416.4- ' - . - Catch basin/area drain
Est. ate of completion/inspection: 4- (; ,0( 7 Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: 4,,,1 Ft �_ ` „ �,,� Manholes
Address: /G?oo 5 ' i c t .�-( t) ' Rain drain connector
City: 4 0 .4 , i , I State: OR I ZIP: l' 701:/ Sanitary sewer (no. lin. ft.)
Phone - 7 Fax:6(2-7 Si E-mail: y Storm sewer (no. lin. ft.)
CCB no.: 2 /9C{ Plumb. bus. reg. no: �- -1L1,q Water service (no. lin. ft.) . ZCit ,55 ` P 55:z2
City /metro lic. no.: / Fixture or item:
Absorption valve
Contractor's representative signature. 2- - - _ - Back � Back flow preventer
Print name: I t4.t_('r A Date: Z.---.11,-c> / - Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s) •
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
OWNER Fixture/sewer cap
Name (print): 61-x� (,�,,j >e/ Floor drains/floor sinks/hub
y -�,�/ 7L Garbage disposal
Mailing address: /
GS �� Hose bibb
City: 7 ,, I State: efk I ZIP: '2_2j Ice maker
Phone: ' -Q Two I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other. _
Phone: I Fax: 1 E -mail: Total i3
Not all jurisdictions accept credit cards, please call jurisdiction for more information N otice: This permit application Minimum fee $ 77 _
O Visa 0 MasterCard expires if a permit is not obtained Plan review (at %) $
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $ f. go
Expires TOTAL $ 73,3
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 4444616. (WW/COM)
PLUMBING PERMIT FEES:
i PRICE TOTAL New 1 and 2- family dwellings only: '
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures In PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavato 16.60 for each utility connection)
ry One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL -
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Ftoor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60 '
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
pemtit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavatory
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
• Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' i 55.00 Water Heater
'/` Other Fixtures
Water Service - each additional 200' 46.40 (Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40 .
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device' 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
,L• 3Z
8% STATE SURCHARGE X 5
**PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $2¢ yb1
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
** All New Commercial Buildings require plans with isometric or riser diagram and
plan review. - -- - _ - - - - - - _ - -
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