Permit •
''`., ... CI ± TY‘OF TIGARD
PLUMBING PERMIT
1:r ° . COMMUNITY DEVELOPMENT PERMIT #: PLM2007 - 00525
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 11/29/2007
PARCEL: 2S103BD -01200
SITE ADDRESS: 12630 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: NIX PARTITION LOT: JURISDICTION: TIG
PROJECT: NIX
Project Description: Connect existing house to sewer service, less than 100'. Reimbursement District #18 fee paid this
date. Septic tank must be pumped, filled and inspected.
CLASS OF WORK: ALT 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
LOY & 0 SW 1 121ST 2 NIX
126 30 Description Date Amount
12630
TIGARD, OR 97223 [PLUMB] Permit Fee 11/29/2007 $72.50
[TAX] 8% State Surcha 11/29/2007 $5.80
Phone : 503 -590 -4810 Total $78.30
Contractor:
PACIFIC GROUND WORKS
BOX 6613
AL OHA, OR 97007 REQUIRED ITEMS AND REPORTS
ALOHA,
Contact # : PRI 503- 649 -8002
Reg #: LIC 152746
PLM 34 -45IPB
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.
O
Issued _ / i eiz ztr( , Permittee Signature:0 a
2
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Plumbing Permit Miplication
Building Fixtures FOR OFFICE USE ONLY '
City of Tigard Received // M 4,7 Permit No.: , L�/ O - 5 5
a 13125 SW Hall Blvd., Tigard, OR 97223 plan Re
-
Phone: 503.639.4171 Fax: 503.598.1960 Plan vtew
Date/By: Other Permit No.: 6� 9 D67 n/1 2,9 2
Inspection Line: 503.639.4175 y ( N
T I G A R D Date Ready /By: Juri ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: / G Supplemental Information
. TYPE OF WORK . FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description Qty. Ea. I Total
❑ Addition/alteration /replacement ❑ Other: New 1- 2- family 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: /236 5 ,Z/ i Catch basin or area drain 16.60
City /State /ZIP: �rG 0 e 97z7 ' Drywell, leach line, or trench drain 16.60
I o Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Project name: /�iIX
Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft. / Page 2 5,00
Storm sewer (no. linear ft.: _ ) Page 2
Subdivision: ,Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
( n- S ex (c7 1 5 lq , d& -(• SPlt> -Ci' Backwater valve 16.60
Clothes washer 16.60
��� Dishwasher 16.60
ROPERTY OWNER ( ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: 2 A/ 1(
o Expansion tank 16.60
Address: /Z6 "c) 5-6i J /a/ Fixture /sewer cap 16.60
City/State/ZIP: / /l� , 6e 9 777.3 Floor drain /floor sink/hub 16.60
Phone: (95 ) i..../37 C3 Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT, PERSON 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: A,- d /'-,6 /' Water heater 16.60
Address: D - v /3 Other:
City/State /ZIP: / At t h e ,„ _ op ^-, a . ` Subtotal
3 / f ( ✓ `'J�4 � Ld/c ( G / / Minimum permit fee: $72.50 ��
Phone: Fax: Residential backflow minimum permit fee: $36.25
CCB Lic.: /S �74/ Plumbing Lic. no.: Plan review (25% of permit fee)
State surcharge (8% of permit fee) .± . e
Authorized signa
TOTAL PERMIT FEE 7 Fl. 3
Print name: Date: ./ "" • I 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.
t' Building \Permits\PLMF- PermitApp.doc 12/27/06 440- 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 Fee: • • . ° -
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
•
Storm & Rain Drain - 1st 100' 55.00 Valuation:, Permit Fee:
$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
FI%tIII'e'Or,Item Q • 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 Plumbing Installations
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees ❑ Any new commercial building with water service 2" and
Quantity by (Fixture) Work Performed greater, except systems designed and stamped by licensed
.Fixture Type: Replace engineer.
Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagram
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain/sink - 2" that meet the qualifications above.
-3 "
- 4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued. .
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i.\Buddmg\Permits\PLM- PermitApp doc 12/27/06
®RVA L T. ADE JOB INVOICE
BVER'S lima ERFlICE, 9NC.
P.O. BOX 549 Wants morn.
_OREGON CITY, OREGON 97045
����` D 656-3326 CUSTOMERS ORDER NO DATE ORDERED
m3o32S 12 -5 -07
ORDER TAKEN BY DATE PROMISED ❑ A M.
Grace 12 -6 ❑ P.M.
BILL TO - PHONE
David Nix 590 -3028
ADDRESS MECHANIC
14411 SW Teal Blvd. #100 B
CITY 6 HEL�
Beaverton, 97008
JOB NAME AND LOCATION
12630 SW 121st. Ave, -Tiq. ❑ DAY WORK
❑ CONTRACT
DESCRIPTION OF WORK
Ord: MOM - Marcia Nix 590 -4810 ❑ EXTRA
Fax- 579 -8358
OUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT
•
a 4,)
Tank primping
I -
HOURS LABOR AMOUNT
TOTAL
•
MECHANICS @ MATERIALS
HELPERS @ TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR TAX
completion of the above described work.
SIGNATURE DATE COMPLETED
TOTAL
CITY. OF TIGAIAD
BUILDING DIVISION PERMIT #: PLM2007-00525
13125 SW Hall Blvd., Tigard, OR 97223
DATE ISSUED: 11/29/2007
Phone: (503) 639-4171 AwNoVIIA
Inspection Requests (24 Hrs.): (503) 639-4175 - IL
INSPECTION WORKSHEET FOR DATE: 1216/2007 TIME: 7:06AM PAGE: 64
SITE ADDRESS: 12630 SW 121ST AVE CLASS OF WORK:
SUBDIVISION: NIX PARTITION LOT #: TYPE OF USE:
PROJECT NAME: MX
DESCRIPTION: Connect existing house to sewer service, less than 100'. Reimbursement District #18 fee paid this
date. Septic tank must. be pumped, filled and inspected.
OWNER: NIX, LOY & MARSHA PHONE #: 503-690-4810
CONTRACTOR: PACIFIC GROUND WORKS PHONE #: 503-6498002
Inspection Request Scheduled For: Date: 12/6/2007 Pour Time:
Code # Inspection Description Confirm # Contact # Message
Sanitary sewer 060886-01 503-314-0798
Corrections/Comments/instructions:
lit ■-•0-e-ok P% e VUF4-e :o
PASS PARTIAL APPROVAL ri CANCEL I I NO ACCESS
I I FAIL 7 CALL FOR INSPECTION ADDITIONAL FEES ASSESSED
Inspector: ( \ Date: 12;1 61 6'7 Phone #: (503) 718-