Permit C ITY OF TIGARD PLUMBING PERMIT
� y;� DEVELOPMENT SERVICES DATEESSU 2g/gg 9 -00192
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS: 15875 SW 72ND AVE PARCEL: 2S112DC -00500
SUBDIVISION: FANNO CREEK ACRE TRACTS ZONING: I -P
BLOCK: LOT: 040 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: B FLOOR DRAINS: 1 TRAPS:
STORIES: WATER HEATERS: 2 CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 3 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 3 WATER LINE: ft
DISHWASHERS: 1 RAIN DRAIN: ft
Remarks: Moving 1 -sink, 1- dishwasher, 1 -2" floor drain, and 1 -water heater. Capping 3- lavatories, 3 -water closets, and
1 -water heater.
FEES
Owner:
Type By Date Amount Receipt
PACIFIC REALTY PRMT DST 6/28/99 $126.50 99- 316454
15350 SW SEQUOIA PKWY #300 MISC DST 6/28/99 $6.32 99- 316454
PORTLAND, OR 97224
Total $132.82
Phone 1: }A
Contractor:
DEAN WARREN PLUMBING
3111 SE 13TH
PORTLAND, OR 97202 REQUIRED INSPECTIONS
Phone 1: 236 -4152 Top -out lnsp
Reg #: LIC 172 Misc. Inspection
PLM 26-83P6 lnsp existing /capped fixtures
Final Inspection
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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.
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Issued By: ` _i �/l Permittee Signature: .;
Call (503) 63 4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF•TIGARD Plumbing Permit Application Plan C
13125 SW HALL BLVD. Commercial and Residential Recd •
TIGARD, OR 97223 Date Recd ' /S 9
(503) 639 -4171 Date to P.E.
Print or Type Date to DST
A.tei Incomplete or illegible applications will not be accepted Relat # / e 9 9 a37
- p 1 %R 9 - Go i to, Called to A3-99
Name of Development/Project FIXTURES ;(individual) .51: QTY : PRICE = ' AMT
Job I EPT, OF hiu,r.AN • REsou. $ Sink I• )11P,,�. /11. 5-e
Address Street Address �� Suite Lavatory j ' 9:99" , 5C
I a 75 s IA, a Tub or Tub /Shower Comb.
Bldg # Cit)/State Zip Shower Only 9.08.
TJ 64RaI 9. -) a a t-( Water Closet r
me . 4b 3L,/ "4
Ar e.-7" u s "( Dishwasher / lr //.3®
Owner ailing Address s act ut Oi.R Suite Garbage. Disposal 940
1 63`5O sp.) p kw ./ 3 o 0 Washing Machine 9.88.
!State Zip Phone Floor Drain/Floor Sink 2" 9 , //" 5 O
Name 3" /yam , I j
Q i P ! • 0. �l l4 M.a ' 1"�6: So tozr..e. Yr 4" +AO
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind - 9.88 - 4 . co
Gas piping requires a separate mechanical permit. c f/.5.0 o` . -Cu
City Set �`i Phone Laundry Room Tray 9.88.
Urinal 9.00
Name
b e r: teR 'i%i p Lei' 6-, Other Fixtures (Specify) 9.00
Contractor Mailing Address Suite 9.00
31 ►I sms 9.00
Prior to permit ty /State Zip Phone Sewer - 1st 100' 30.00
issuance, a copy 0 P3 -1-1,,,,,,.,4 q 7 ao Q3 G-141 Sit Sewer - each additional 100' 25.00
' licenses are Oregon Const. Cont. Board Lic.# Exp. Date
' / equired if 0 "7'D. ( / 3 o� x79 Water Service - 1st 100' 30.00
expired in COT Plumbing Lic. # Exp. Date Water Service - each additional 200' -• 25.00
database a e ?* P 6 ) P f .31 4°I Storm & Rain Drain - 1st 100' 30.00
Name 4 -30 -cso Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space 25.00
or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device -
Engineer City /State Zip Phone Residential Backflow Prevention Device' 15.00
(Irrigation timing devices require a separate
Describe work to be done: restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes O No O Any Trap or Waste Not Connected to a Fixture 9.00
Residential 0 Commercial O Catch Basin 9.00
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Additional description of work: ,. / — 0 W Insp. of Existing Plumbing 40.00
R A OA 5 L D f .) ° 5 / MI��. 1 - +� 14� 1 ° �® Per/hr
Specially Requested Inspections 40.00
co Ely. O o'F3 — LAv 3 -wc. I ®IseH per/hr
Rain Drain, single family dwelling 30.00
Are you capping, moving or replacing any fixtures?
Grease Traps 9.00
Yes O No O
If yes, see back of form to indicate work performed by QUANTITY TOTAL •
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Isometric or riser diagram is required if Quantity Total is > 9
WORK COULD RESULT IN INCREASED SEWER FEES. *SUBTOTAL '-- I ,5
1. hereby acknowledge that I have read this application, that the information
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE 32.
that plans submitted are in compliance w' ,Oregon State Laws.. (
• Signature of O ner /A Date '"'PLAN REVIEW 25% OF SUBTOTAL .
'r'' V /S 1 99 Required only if fixture qty. total is > 9 TOTAL / 3 $ a
' ntact Person Name Phone
*Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
1 6-Le I...)O.i a3G-Li 1 Sa Prevention Device, which is $15 + 5% surcharge
"All New Commercial Buildings require plans with isometric or riser diagram
( ------ r;) h 4 l' j .
and plan review
I: ldstslplumapp.doc 7/2/98 Tl -
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved. I Replaced Removed /Capped
Sink 1
Lavatory 3
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher j
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2" 1
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
X \ST/ t! IC IJEI • G
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