Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2000-00306
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED:
SITE ADDRESS: 10980 SW 115TH AVE PARCEL: 1S1 34AC 02642
SUBDIVISION: ENGLEWOOD NO.3 ZONING: R -4.5
BLOCK: LOT: 208 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF 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: Installation of back flow prevention device.
FEES
Owner:
Type By Date Amount Receipt
DAVENPORT, KEVIN S AND PRMT JMT 8/18/00 $50.00 000
KATHLEEN V 5PCT JMT 8/18/00 $4.00 000
10980 SW 115TH
TIGARD, OR 97223 Total $54.00
Phone 1:
Contractor:
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
Reg #:
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.-e-- Permittee Signature: ���1 _ t -e_l-.. (�
tt Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
CITY OF TIGARD Plumbing Permit Application Plan Check#
13125 SW HALL BLVD. Commercial and Residential Recd B
TIGARD, OR 97223 I6' Date Rec' g
(503) 639 -4171 ( Date to P.E.
Print or Type Date to DS
Incomplete or illegible applications will not be accepted R erm edS W # - ��
Related WR #
Called
Name of Development/Project FIXTURES (individual) QTY ` PRICE AMT
Job s Q Av Tl 150- Sink 11.50
Address Street Address Suite Lavatory 11.50
109,g U 5 I Mil._ Tub or Tub /Shower Comb. 11.50
Bldg # City /State Zip Shower Only 11.50
TI ( 0 ce CI722 -3
Water Closet 11.50
Nang t fJ ! � l 01%4.) - 90{2- Urinal . 11.50
Owner Mailing Address ( �uite Dishwasher 11.50
( CFI 0 SL,-\ 11 (Vk_ Garbage Disposal 11.50
City /State Zip Phone Laundry Tray 11.50
m 2-0 c_ 4 -5 8 3`{
Name Washing Machine /Laundry Tray 11.50
-�jJ l N k ! �'M I,
r^� �'E -N P - Floor Drain /Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" 11.50
Srac PA itli.TV rte.
4" 11.50
City /State Zip Phone
Water Heater 0 conversion 0 like kind 11.50
Name Gas piping requires a separate mechanical permit.
Ov4 tJ ii--- MFG Home New Water Service 32.00
Contractor Mailing Address Suite MFG Home New San /Storm Sewer 32.00
Hose Bibs 11.50
Prior to permit City /State Zip Phone Roof Drains 11.50
issuance, a copy
Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if Other Fixtures (Specify) 15.00
expired in COT Plumbing Lic. # Exp. Date
database
Name
Architect Sewer- 1st 100' 38.00
- - - or Mailing Address . Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00
Engineer City /State Zip Phone Water Service - each additional 200' 32.00
Describe work to be done: Storm & Rain Drain - 1st 100' 38.00
New t4 Repair 0 Replace with like kind: Yes 0 No 0 Storm & Rain Drain - each additional 100' 32.00
Residential 931( Commercial 0
Additional description of work: Commercial Back Flow Prevention Device 32.00
Residential Backflow Prevention Device' 1 19.00 l l
Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes 0 No 0 Inspections per /hr
If yes, see back of form to indicate work performed by Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE ' Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES.
I hereby acknowledge that I have read this application, that the information QUANTITY TOTAL
given is correct, that I am the owner or authorized agent of the owner, and Isometric or riser diagram is required if Quantity Total is > 9
that plans submitted are in compliance with Oregon State Laws. *SUBTOTAL
Signa�t re A O ner /Agent Date u
, r, U ,� ta � /��Ub 8 /a SURCHARGE h
Contact Person Name Phone v �
"PLAN REVIEW 25% OF SUBTOTAL
1 BATH HOUSE $178.00 Required only if fixture qty. total is > 9
2 BATH HOUSE $250.00 TOTAL •
3 BATH HOUSE $285.00 -
(This fee includes all plumbing fixtures in the dwelling and the first *Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Prevention
100 feet of sanitary sewer storm sewer and water service) Device, which is $25 + 8% surcharge
"AII New Commercial Buildings require plans with isometric or riser diagram and
plan review.
I: \dsts \forms\plumapp.doc 11/18/99
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
I: \dsls \forms\plumapp.doc 11/18/99
C4TY OF TIGARD BUILDING INSPECTION DIVI ON Arr
24 -Hour Inspection Line: 639 -4175 Business Lin • . 639 -4171 MST `
BUP
Date Requested .2 1 `I AM PM BLD
Location / 4 ?El 0 5 4 // 5 4 'P Suite
MEC
Contact Person Ph . 53 — 95" 3 q a G ---4,a30 c.
Contractor Ph '' -
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Foundation Access: -. FPS
Ftg Drain SGN
Crawl Drain Inspection otes: , , j 7 '
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation ,r� �� f� Q - - 1 am/ Drywall Nailing Ili �..�i1 n �/� EL I (E_I j �.^-7s \ C
Firewall r
Fire Sprinkler \A * W .A.-- e__%...‘..,
Fire Alarm
Susp'd Ceiling � / ��
Roof . " L v" d l'"' L ss �.L_ r
Misc:
Final ' /� �_ \�� L.C.--- x."... PASS PART FAIL
v �� � � Cam..
4 • LUMBING _
= ost & Bea , �'
Under Slab
Top Out
Water Servic
Sanitary Sewe
Rain Drains
Final
PASS PART FAI `
MECHANICAL et-T \
Post & Beam
Rough In ____P -
Gas
Smoke e Dampers -
Final 1.11Warl
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE K
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA 1 q Approach /Sidewalk Date- `'[ v � Inspector v lI Ext (
Other
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.