Permit CITY OF 'HOARD
PLUMBING PERMIT
i I DEVELOPMENT SERVICES PERMIT #: PLM2006 - 00218
� 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 5/17/2006
PARCEL: 2S 103BA -00900
SITE ADDRESS: 12330 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Line work to connect sewer. Septic system to be pumped and filled or removed.
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 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: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
MARY ANNE/ ANDERSON
12330 SW 121ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 5/17/2006 $72.50
[TAX] 8% State Surcha 5/17/2006 $5.80
Phone : 503- 984 -4882 Total $78.30
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # :
Reg #:
•
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: Permittee Signature it �.. j_dA // _//�J
_ z, Z ._______
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business. y.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Building Fixtures
Plumbing Permit Application , R , E VEi� FQR OFFICE USE ONLY
IN `J g M AY 1 2006 D /B y l / / 7 Q6, 46 Pe rmit No.: Pu c 0 v�a«olv .- cr'
Ci of Ti and "`yyyJJJ
v 13125 SW Hall Blvd., Tigard, OR 97223 r P l an Revie
C : ' Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No.gWe 7 -. 90
T I G A RD Inspection Line: 503 C ITY OF Ti ARD �►V Date ReadyReady/By: Ju °$k ' ® See Page 2 for
. Internet: www.tigard - or.gov BUIL Notified/Method: Supplemental Information
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TYPE OF WORK . FEE* S REDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition /alteration /replacement ❑ Other: New 1 dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 1 r C43 / 2 ( c �/ Catch basin or area drain 16.60
City /State /ZIP: '� ,' ,``l/ - cud, Q FR_ 2f R 7 2 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: t I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street /directions to job site: /j . / Manholes 16.60
1 2 I - 4_ U,JcuriA -.( ! Y S c_41 Rain drain connector 16.60
' tu I V D 12. ( Sanitary sewer (no. linear ft.: Page 2
Storm sewer (no. linear ft.: ) Page 2 •
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Back flow preventer Page 2
g k Aid at_ -1- .d. a/A.../ Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
PROPERTY OWNER 1 CI TENANT
/ Ejectors/sump 16.60
Name 1 4I j _ 4 _ t . :111/` / - // / Expansion tank 16.60
Address: r( , 13-6 Y 2:5 Fixture /sewer cap 16.60 •
City /State /ZIP: l r r p ,{ f t 6 q q - / Floor drain /floor sink/hub 16.60
Phone: (51 )5 I t 4 � 4 f� 3 2- Fax: ( ) Garbage disposal 1 6.60
❑ 'APPLICANT ❑ CONTACT PERSON
CANT Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City /State /ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax: : ( ) Sink/basin /lavatory 16.60
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: Water heater 16.60
Address: Other:
City /State /ZIP: Subtotal
Minimum permit fee: $72.50 ^ ••''''
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 9K.Sf/
CCB Lic.: C Plumb'. Lic. no.: Plan review (25% of permit fee)
/ State surcharge (8% of permit fee) 6" ; •
Authorized signature:
iI I . _1A. _ . /�i'_/ / ...e_..' I TOTAL PERMIT FEE , ,
Print name: A - i Affil Date:S This permit application expires if a permit is not obtained within
- - 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I:\ Building \Perrnits\PLMF- PermitApp.doc 04 /06/06 440 -4616T(10 /02/COM /WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information ,.
Fee Schedule: Residential Fire Suppression Systems:
'Site Utilities -., - - Qty. . -Fee (ea) Total Square Footage: - Permit Fe: '.- .
Footing drain - 1" 100' 55.00 0 to 2,000 $115.00
Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00
3,601 to 7,200 $220.00
Sewer - 1st 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service - 1st 100' 55.00 Medical Gas Systems:
Water Service - each additional 100' 46.40
Valuation: Permit Fee: -
Storm & Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each
Fixture or Item . Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and
including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee $36.25) 27.55 and including $25,000.00.
Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Fixture Work: Plan Review for Complex Structures
Are you capping, adding or replacing fixtures? If "yes ", A "complex structure" is defined as an installation of a plumbing
please indicate work performed by fixture. Failure to system that meets any of the following criteria
accurately report fixtures could result in increased sewer fees *. Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building.
Fixture Type: Replace ❑ Any new exterior plumbing site utilities.
Previous Capped Added Existing ❑ A commercial building with installation, alteration or addition
Baptistry /Font of nine (9) or more new or relocated plumbing fixtures.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities
- Jacuzzi /Whirlpool providing services to human beings.
Car Wash -Each Stall ❑ Plumbing installations, alterations or additions to food service
-Drive Thru facilities where new plumbing fixtures, including interceptors,
Cuspidor /Water Aspirator are being installed for the food service area.
Dishwasher - Commercial ❑ Any new residential building containing three (3) or more
- Domestic dwelling units.
Drinking Fountain
❑ Any NFPA 13 -D multipurpose fire sprinkler system.
Eye Wash
Floor Drain /sink - 2" _ gut—;* 2 s o f pl with a of the above.
-3" =
-4 „
Car Wash Drain Isometric or Riser, Diagram . '
Garbage - Domestic ❑ Isometric or riser diagram is required for new buildings
Disposal - Commercial three (3) or more stories in height.
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory .
- Bradley
- Commercial
- Service
Swimming Pool Filter
Washer - Clothes *Note: If the fixture work under this permit results in an
Water Extractor
Water Closet - Toilet increase of sewer EDUs, a sewer permit will be issued and
.Urinal fees assessed for the sewer increase must be paid before the
Other Fixtures: _ plumbing permit can be issued.
i:\ Building \Pennits\PLM- PermitApp.doc 07/06/05 •
CITY OF TIGARD LIp -
BUILDING DIVISION • , r. PERMIT #6 _, 610 t :
13125 SW Hall Blvd., Tigard, OR 97223 �� ISSUED;_
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Phone: (503) 639 -4171 'gh i'�i "if
Inspection Requests (24 Hrs.): (503) 639 -4175 .'
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INSPECTION WORKSHEET FOR DATE: TIME: / PAGE:
SITE ADDRESS: f a 33 0 ; -d ,CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: #:
CONTRACTOR: _.� --4 PHONE #:
Inspection Re st Scheduled For: Date: 6 - a 7 - 0 5° Pour Time:
Code # Inspection Description Confirm # Contact # Message
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Inspector: 014 cA--------- Date: ° Phone #: (503) 718- 24/21'
CITY OF TIGARD
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BUILDING DIVISION • „ ,- ,.
PERMIT #: PLIVI2006-00218
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 5/17/2006
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Phone: (503) 639-4171
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Inspection Requests (24 Hrs.): (503) 639-4175
INSPECTION WORKSHEET FOR DATE: 6/ TIME: 7:16AM PAGE: 6
SITE ADDRESS: 12330 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: ANDERSON
DESCRIPTION: Line work to connect sewer. Septic system to be pumped and tilled or removed.
OWNER: ANDERSON, MARY ANNE/EDWARD PHONE #: 503-9E344882
CONTRACTOR: OWNER PHONE #:
Inspection Request Scheduled For: Date: 6/23/2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
39$ Plumbing final 032282 503.481 Y
Corrections/Comments/Instructions:
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I nspector:P/V\A-- Date: ' - • , Phone #: (503) 718- .24,47