Permit CITY TIGARD PLUMBING PERMIT
�r DEVELOPMENT SERVICES PERMIT #: PLM2002 -00272
'�' II 13125 SW Hall Blvd., T igard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/8/02
SITE ADDRESS: 15875 SW 72ND AVE BLDG -B #200 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: FLOOR DRAINS: TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 2 URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Tenant Improvement - demo two sinks and rough -in two new sinks
FEES
Owner:
Type By Date Amount Receipt
PACIFIC REALTY ASSOCIATES PRMT JMT 7/8/02 $72.50 HAND
15350 SW SEQUOIA PKWY #300 -WMI 5PCT JMT 7/8/02 $5.80 HAND
PORTLAND, OR 97224
Total $78.30
Phone 1:
Contractor:
REQUIRED INSPECTIONS
Phone 1: Rough -in Insp
Reg #: Final Inspection
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.
P ermittee Signature: :a
Issued By: _�c.ein/ g
Call (503) 39 -4175 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application
A Date received: 7 g ovti Permit fe/n ?. a -7
f��• Ci of Tigard
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 Dateissued: By: I Receiptno.•
Land use approval: Case file no.: Payment type:
7 V•1'I•: OF Pi;R1I11•
0 1 & 2 family dwelling or accessory Commercial/industrial 0 Multi - family 0 Tenant improvement
0 New construction = ' Addition/alteration /replacement 0 Food service 0 Other:
.1011S11 E INFORi11A1 ION FEE SCHEDULE (for special information use checklist)
Job address: ) 5 ) S Sw 7 a. - Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: 2 o New 1- and 2- family dwellings only:
(includes 100 ft. for each utility connection)
Tax map/tax lot/account no.: SFR (1) bath
Lot: Block: 'Subdivision: _ SFR (2) bath
Project name: �,[} j IQ L F R AA E. N SFR (3) bath
City /county:? j 6-A .d ZIP: 9.-7 a y Each additional bath/kitchen
Description and location of work on premises: 0 g..}... p a Site utilities:
S i %Al k S -- Ick O ug l b., (p S i ry k S Catch basin/area drain
Est. date of completion/inspection: A Ul ( -tom Drywells/leach line/trench drain
PLUMBING CON "IRACIOIi Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: 0 EA K WA R a sty P L g 6-. Manholes
Address: 3't 1 k $ e.. ► 3 V"-- Rain drain connector
City: Ph 12 r L A +'+?� I Stated I ZIP: g Z o�2.0 _Sanitary sewer (no. lin. ft.)
Phone;a3 (o- 4 15 — l Fan: 36- v1 - 13I E-mail: _ Storm sewer (no. lin. ft.)
CCB no.: O % 7 R 'Plumb. bus. reg. no: a (,) 83 PB Water service (no. lin. ft.)
City/metro lic. no.: 1 CI 8 i Fixture or item:
Contractor's representative signature: - Absorption valve
� Back flow preventer
Print name: E. 11-o wS Date: S 0 Backwater valve
Basins/lavatory
Name: l�� € N ,.../ U - 0 Lo Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: 'State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
S u ■ ` 3 0o Floor drains/floor sinks/hub
Name (print): PJ4 c __-7--g u Si— Garbage disposal
Mailing address: j .5 5o 6 w S FG2u 4 n� Pkwy _ Hose bibb
City:T 1 &AA I stateo� ZIP: 9 7 as t-( Ice maker
Phone: ( y — 63 obi Fax: 1E-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) q
Owner's signature: Date: Sump
Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: 'ZIP: Other:
Phone: I Fax: (E -mail: Total y
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $ 7a.
O Visa 0 MasterCard Plan review (at %) $
expires if a permit is not obtained a lr
Credit card number: / / within 180 days after it has been State surcharge ( 8% ) .... $ c.5-
Expires accepted as complete. TOTAL $ ? 8 3e, _
Name of cardholder as shown on credit card
$
Cardholder signore Amount 440-4616 (6/00/COM)
PLUMBING PERMIT FEES:
PRICE TOTAL ` New 1 and 2-family only:
FIXTURES (individual) . QTY (ea) •AMOUNT'' (includes all plumbing 'fixtures in PRICE TOTAL
Sink t 1 16.60 [w & , the dwelling and the first100 ft. QTY .(ea) AMOUN
Lavatory 16.60 for each utility connection)
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/Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
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/
permit. - 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
16.60 Urinal
Other Fixtures (Specify) 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' 55.00 Water Heater
Water Service - each additional 200' 46.40 Other Fixtures
(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 . 62.50
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 r7a 5d
8% STATE SURCHARGE S0
**PLAN REVIEW 25% OF SUBTOTAL .
Required only if fixture qty. total is > 9
TOTAL 178-1°--
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $38.25+ 8% state surcharge.
** All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
i:\dsts \forms\plm- fees.doc 12/26/01