Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2002-00430
� 131 SW Hall Blvd., Tigard; OR 97223 (503) 639 -4171 DATE ISSUED: 11/8/02
SITE ADDRESS: 14620 SW 76TH AVE 054 PARCEL: 2S112BD -00100
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
CLASS OF WORK: ALT GARBAGE DISPOSALS: 1 MOBILE HOME SPACES:
TYPE OF USE: MF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R1 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: 1 OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: 1 WATER LINE: ft
DISHWASHERS: 1 RAIN DRAIN: ft
Remarks: 1 lav, 1 dishwasher, 1 garbage disposal, 1 sink, 1 water closets.
FEES
Owner:
Description Date Amount
WASHINGTON CO. HOUSING AUTHORITY
111 NE LINCOLN ST [PLUMB] Permit Fee 11/8/02 $83.15
#200 - MS63 [PLUMB] Permit Fee 11/8/02 $0.00
HILLSBORO, OR 97124 -3082 [TAX] 8% State Tax 11/8/02 $6.65
[TAX] 8% State Tax 11/8/02 $0.00
Phone 1: 503- 846 -4794
Total $89.80
Contractor:
ALBERTA PLUMBING
LEWIS TRANER
PO BOX 55031 REQUIRED INSPECTIONS
PORTLAND, OR 97238
Phone 1: 503 331 - 0657 Final Inspection
Reg #: LIC 96782
PLM 26 -707PB
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
f
Issued By: = A,, `! 1 Permittee Signature: A/
Call (503) 639 -4175 by 7:00 P.M. for an inspection neede• e next business day
Building Fixtures
Plumbing Permit Application OFFICE USE ONLY
City of Tigard Date received: ��- Permit no.:Pal �a -) 0 /f 3,Q
1 , -la '� -(V
• 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 Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial /industrial rA Multi - family ❑ Tenant improvement
❑ New construction ❑ Addition /alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist 4
Job address: ! 714 7,Q 5j) 7i '7" F °� Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax map /tax lot account no.: (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: Block: Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion /inspection: Drywells /leach line /trench drain
Footing drain (no. lin. ft.)
' PLUMBING CONTRACT,OR'. ,
'�« Manufactured home utilities
Business name: - r Manholes
Address: r 6 ;,_ ( 0 Rain drain connector '
City: , I Stat: �),--- ZIP: F74 Sanitary sewer (no. lin. ft.)
�� ?/ ,,fig Storm sewer (no. lin. ft.
Phone: � � a� E -mail: ( ft.)
CCB no.: A!. , ,, Plumb. bus. reg. no: i �, _ Water service (no. lin. ft.)
City /metro ic. no.: Fixture or item:
/ Absorption valve
Contractor's representative signature:
ice _ Back flow preventer
AI
Print name: , _ � � IP ate: ,, — a (---, Backwater valve
CONTACT PERSON Basins /lavatory i
Name:
'2111111;M Mr, Clothes washer
Address: Dishwasher i
Drinking fountain(s)
City: State: ZIP: Ejectors /sump
Phone: D x: E -mail: Expansion tank ,
':,'.. ; ^` OWNER «d' :+,. - ... Fixture /sewer cap
Name (print): Floor drains /floor sinks/hub
Mailing Garbage disposal
ailing address:
Hose bibb • -
City: State: ZIP: Ice maker
Phone: Fax: 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) 1
Owner's signature: Date: Sump
ENGINEER Tubs /shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: State: ZIP: Other:
Phone: I Fax: E -mail: Total 5-
Not all jurisdictions accept credit cards, please call jurisdiction for more information.
Minimum fee $
Notice: This permit application
❑ Visa ❑ MasterCard expires if a permit is not obtained o Plan review (at /o) $
o
Credit card number: / / within 180 days after it has been State surcharge (8%) .... $ i.
Expires TOTAL $ ♦ •
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6 /00 /COM)
PLUMBING PERMIT FEES:
:
FIXTURES ,.(indiVidual) QTY : Otimbing :" PRE TOTAL
Sink 16.60 the dweIIing and ttje fifti108:itt AMOUNT:
:
Lavatory 16.60
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 ,t.1-
„ . ,„ ,
Gas piping requires a separate mechanical rtiovedi. 1,:l3eplOc4V
permit. , „ ' ; '
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 1,6.60 Water Closet
Other Fixtures (Specify) 16.60 Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
FloorDrain/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
8% STATE SURCHARGE .
**PLAN REVIEW 25% OF SUBTOTAL Ott y,PM:fai
Required only if fixture qty. total is > 9 eigta',S,IfgAT
TOTAL $
* 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 2 sets of plans with isometric or riser
diagram for plan review.
iMsts\forms\pim-fees.doc 12/26/01 •
CIT 24 -Hour
BUILDING Inspection Line: (503) 639_4175
INSPECTION DIVISION Business Line: (503) 639 - 4171 MST
BUP
Received Date Requested / / /0 AM PM BUP
Location / 1 6 2 76 ku� Suite 744- 5 I MEC
Contact Person Ph ( ) 7 cl w 1/ S,6 PLM , --0 v `f 3 b
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Ftg Drain Access: ELR
Crawl Drain
Slab Inspection Notes: `� StT
Post & Beam �,, n
Ext Sr ea /Sh \/ Z `-s/�/ it-4 % f
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler i .4/'
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab -
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Otr -
. .
PART FAIL
ANICAL
Post & Beam
Rough -In
-
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE ri Please call for reinspection RE: ❑ Unable to inspect — no access
Fire Supply Line
ADA
Approach/Sidewalk ae ! nspector / 7�
Other:
Dt I //� Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL