Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2002 -00497
° ' 111 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/23/02
SITE ADDRESS: 11555 SW 88TH AVE PARCEL: 1S135DD -03300
SUBDIVISION: PARK PLACE GARDEN APT. ZONING: R -12
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: MF WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: 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: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Back flow preventer located in bed north of driveway. Driveway is located on south side of community bldg and
leads to office
FEES
Owner:
Description Date Amount
PARKER, JEROME W TRUSTEE
BY SUMMIT REAL ESTATE MANAGEME [PLUMB] Permit Fee 12/23/02 $36.25
5320 SW MACADAM AVE [TAX] 8% State Tax 12/23/02 $2.90
PORTLAND, OR 97201 Total $39.15
Phone :
Contractor:
HK &T
14985 SW TUALATIN - SHERWOOD RD
SHERWOOD, OR 97140 REQUIRED INSPECTIONS
RP /Backflow Preventer
Phone : 503 625 - 5277
Reg #: LIC 14112
PLM 6964LCB
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
Issued By: • Permittee Signature:
Call (513) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plumbing Permit Application ' . OFFICE USE ONLY
Date received: j1' - 0,_ Permit no.itabg, )2
City of Tigard JI City 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: Receipt no.:
Land use approval: Case file no.: Payment type:
' ,.. , • ?, . TYPE OF' PERMIT . ..- , '
0 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:
h - ' ! JOB SITE INFORMATION - . • • . FEE SCHEDULE special information use checklist)
Job address: C\ S� . h - Description Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: 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: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county:; \.44 I ZIP: 6\--4ZZ71) Each additional bath/kitchen
Description and ocation of work on premises: `1^ txl& W..x��c Site utilities:
\M o. r te, Ike ' ' A . Catch basin/area drain
Est. date of completion/inspection: Drywells /leach line /trench drain
. ' Footing drain (no. lin. ft.)
PLUMBING CONTRACTOR
Manufactured home utilities
Business name: � Manholes
Address: V - \c, C \,,/ I�1. - S\ rwt1^ 14 Rain drain connector
City: \-. .p\ I State:C I ZIP: q .' -\0 _Sanitary sewer (no. lin. ft.)
Phone: 1 .) - 5 ‘-zs--5r}4 -Fax: C 3 I E -mail: Storm sewer (no. lin. ft.)
S
e CB no.: VV.\ I Plumb. bus. reg. no: Water service (no. lin. ft.)
City /metro lic. no Fixture or item:
Contractor's representative signature: — Absorption valve
Back flow preventer
Print name: \ , th, Date: Vim. oZ Backwater valve
_ CONTACT PERSON -. Basins /lavatory
Name: + r\ Gil ,,t,^ Clothes washer
1 ' Dishwasher
Address: \y°\sc> c j Th \��� +� GR'' Drinking fountain(s)
City: Sl- .,�.�.r r + I State:0a, I ZIP: " l -1 \` Ejectors /sump
Phone: ) SZ }} Fax: CZ - i( E -mail: Expansion tank
, OWNER . . • . - . . • Fixture /sewer cap
,(- � Garbage drains/floor disposal
sinks /hub
Name (print): address: / Garbage disposal
Mailing Hose bibb
City: I State: I ZIP: Ice maker
Phone: („ a; S -.5 L7 71 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: State: ZIP: Other:
Phone: I Fax: E -mail: Total
Minimum fee $
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application
0 Visa 0 MasterCard Plan review (at o)
/ / expires if a permit is not obtained State surcharge (8 %) .... $
Credit card number: p within 180 days after it has been TOTAL $
Expires
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440-4616 (6 /00 /COM)
V , -b./ 1 , r• O N (P,--. , .A.v,n�-1 . ( i \ "�"� i' a c, T f9\ S.)---W s,Ik o. -
1
PLUMBING PERMIT FEES:
1, - 7:rgic: ioWA ;,
d SROTAiffsAr44ifaiiiilii,10 %:',:;;';''.<:. , ::- .
'!FIXTURES' ' -' ? '::',4(Olit:::1 „`VAMOUN, fiiii'ClUtfaZaIll;10iitiliiiffigtiiietlii:, PF4cE TOTAL
Sink 16.60 Y
iii4 itiT,e : ', ANibUivr
, r- '.. .4-*• ',.:R :"-* t - .,.. ,,, -.
,forieacheutilityiccinnectionyz 4..,;',:V,
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 7
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 7. '›I' , K 4.QtlifitityliV
, Work ;PerfOilied
w,
==
',,,- --:--- - - -'-. ' --- '.--: - - -- -. ;:--
Gas piping requires a separate mechanical FixtureType:;,,,‹',,,x,,,,, 4 ,.,,,gN ;;,
eW,1 i:;,MoVed'A: vRe 'ARdmtived/
IC, '
,, - ,.,,,--.„ ';',,c,
permit. :. .! '• ,:-,,:', VAI.*%•'."::%-,-..1 •-.3,
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 Urinal
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 ' Va4: t;
Isometric or riser diagram is required if 0A
Quantity Total is >9 .;.1.",` ' Vg,..4
*SUBTOTAL *:•L' ,!-..; ION
8% STATE SURCHARGE °
**PLAN REVIEW 25% OF SUBTOTAL 047,5, ','-f 5,,,..01.g.,., •
Required only if fixture qty. total is > 9 l
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.
iAdstsVorms\plm-fees.doc 12/26/01
1 \
\ ,... — '. • • 574612
;- 4
® „o NEW
PNWS -AW WA ❑ EXISTING
BACKFLOW ASSEMBLY TEST REPORT ❑ REMOVED
PROPERTY / r � ,. �,�- 0 REPLACEMENT
OWNER: . yer PHONE:
MAILING / / ) r / a rA ��
ADDRESS:
-- ,q,�
•
CITY � . S G,�� -, STATE ZIP
ASSEMBLY
ADDRESS:
STREET
❑R.P.B.A.,CI D.C.V.A. ❑ R.P.D.A. ❑ D.C.D.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. ❑ AIR GAP
SIZE: 1 I /149 01 MAKE: , MODEL: ' Z5?
WATER _ SERIAL f�
PURVEYOR: `7> e r..,' � 1
NUMBER: ? (n f 7
ASSEMBLY / / �J
LOCATION: .' CO r" , -° --1 !!/ . s- . /4
i
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A INITIAL TEST
NI CHECK DOUBI 1 <'CHECK: AIR CHECK PASSED '
PRESS DROP (Al CHECK #i INLET FAILED ❑
INITIAL RELIEF VALVE j� OPENED AT: PRESS DROP
TEST OPENED AT ( g )I TIGHT ��° DATE:
RESULTS BUFFER MIN 2 PSID 'LEAKED ❑ Pslu PSID PSID / / 3 /03
A - B = I CHECK #2
MIN 3 PSI
R ELIEF VALVE 'TIGHT / E1g • DID NOT FAILED SYSTEM
PASS ❑ FAIL ❑ 'LEAKED PSID OPEN ❑ ❑ PSI
COMMENTS
REPAIRS
- AND /OR
PARTS
REDUCED PRESSURE ASSEMBLY P. V.B.A. /S. V.B.A. AFTER REPAIRS
_ -q_I CHECK — _ D.C'V_At;":; " - -
TEST PRESS DROP (A) ` CHECK #1 DATE:
RELIEF ' OPENED AT PRESS DROP /
, AFTER OPENED (B) T IGHT PSI
REPAIRS BUFFER '� 2P � I CHECK #2
A - R t.@IIPa I TIGHT ❑ Pp PSID PSID PASSED ❑
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE
ASSEMBLY HAS BEEN TESTED AND MAINTAINED. TN ACCORDANCE WITH ALL APPLICABLE
• .RULES AND REGULATIONS OF THE WATER SYSTEM, AND STATE REGULATIONS.
GAUGE CALIBRATION DATE 06 121 �02 DETECTOR METER READING '
1
3275
TESTER SIGNATURE 2003gRTP '
D. Brad Heath
TESTERS NAME PRINTED P.O. Box 1565 Sherwood OR 97140 5m-625 .
TESTERS ADDRESS �'`� PHONE ti
; j •Heath BackAow Testing
'COMPANY NAME
" - a SERVICE RESTORED
'. REPORT RECEIVED BY: (REPRESENTATIVE OF OWNER) / .
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy
CITY OF TIGARD 24 -Hour •
BUILDING, i Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line:' (503) 639 -4171 MST
' '1 BUP
Received Date Requested /— AM PM BUP
Location r/ 55 7g Y Alt-e Suite MEC
- Contact Person ` -�� l �" Ph ( Q ) 79'3 3 PLM
Contractor Ph ( ) SWR
BUILDING ; e..: ., , Tenant/Owner 7-1 '-- a7-C--e, / z2- ELC
Footing
ELR
Foundation _'. .T �. -5`' F , , .t 1;, ,. lt ...� i ELC
Ftg Drain +''1,.. . � . _ ',, ';. ,�,;.,,.f � s x ..� v./c�
Crawl Drain 4 .,- v k. 3 P c.,,,,,* e ..'z ➢� `:` - .I. y ,�, , "i ••Z 't �+ ' � '' `. z
�( +• t t s, . s �f 1 /l ; mot �.t ol. J'A 0 1 l ..a :3 ,..
Slab Inspectioni l otes: SIT
Post & Beam "" -
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing " `' _
Insulation �/7
Drywall Nailing
Firewall _ (./.''.--
s
Fire Sprinkler ` '
' Fire Alarm f/° _ f'��
Susp'd Ceiling �,�L.- ---
Roof f ,1 1 �..r
t' Other: 7 €,./ (.,,i //
-s Final ( t'
_ _ PASS PART FAIL 3
_ 'PLUMBINGb
Post & Beam
,,
,.,,,.,,„ Under Slab -
Rough -In
Water Service
Sanitary Sewer -
Rain Drains
c Catch Basin / Manhole
Storm Drain
Shower, Pan ''
Other:
Fines - 1
'(PASS PART FAIL
MECHANICAL` -
Post & Beam .
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL _
ELECTRICAL ./ V
°Service i
Rough -In L ;
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 _. 0 Please call for reinspection RE: 0 Unable to inspect — no access
Fire Supply Line / j -'
ADA 1 / / / I__
j .. ),
��
Approach /Sidewalk Date r 1 L! / «` ' Inspector 3 ' Ext
Other:
Final
1 I t� •
t DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL