Permit A , ' CITY OF TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2006 -00112
+ ..� I 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 2/27/2006
PARCEL: 2S 103BD -03200
SITE ADDRESS: 12840 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Line work. Septic 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
RAMIREZ, EDUARDO + LUCIA Description Date Amount
12840 SW 121ST AVE
TIGARD, OR 97223 [PLUMB] Permit Fee 3/30/2006 $72.50
[TAX] 8% State Surchan 3/30/2006 $5.80
Phone : Total $78.30
Contractor:
MICHAEL MCBEE
3039 SE 174TH AVE. REQUIRED ITEMS AND REPORTS
PORTLAND, OR 97236
Contact # : FAX 503- 254 -1070
PRI 503- 239 -2707
Reg #: PLM 55821
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 -000 -I.10 t • gh • R : 2- 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by
calli r • 503 - 246 -6699 • 1- to 332 -2344. - /
Iss ed By: , / / Permittee Sig • re: y . i ejAwi gir !��
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.
•
PluA Permit Asah��l dt{ EIVED FOli OFFI( l: t tiF: (, \I.l
City of Tigard 200 r DDateB • __ 0 - , • Permit N. i I 204,1v-- 00 / /6
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.639.4171 Fax: 503.598.1960 Plan Review No.:
24- Hour Inspection Line: 503.639.4175 CITY OF TIG , _ ),,�, 1. Date/By. Other ,6t See . N ed/Met qI R S e Pen for
Internet: www.tigard- or.gov BUILDING DNI 1 NNotified/Method: S„
Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. ) Ea. Total
❑ Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- famiiy dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
JOB SITE INFORMATION AND LOCATION Fire sprinkler ( sq. ft.) Page 2
Site utilities
h Job site address: /2k . 5, 4 w.,./ : 21 JT- ve , Catch basin or area drain 16.60
City / State/ZIP: '.-7-7‘ ?72 Drywell, leach line, or trench drain 16.60
-
Suite/bldg. /apt. no.: .1 Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 1 10.00
Cross street/directions to job site: he �ti! / ems^ ,c� " ,
Manholes 16.60
A/� ..I{`'�►1. ! 7
Rain drain connector --16.60
Sanitary sewer (no. linear ft./4') ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2
Tax map /parcel no.:
Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK Back flow preventer Page 2
Backwater valve 16.60
.
Clothes washer 16.60
Dishwasher 16.60
f5 PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: � i)va - et 4 , 4 44 /26 z____ Expansion tank 16.60
A ddress: I Z� �S_ W.. (2 f� A/� Fixture/sewer cap 16.60
City / State/ZIP: // j 4 ,e - � /�, 7223 Garbag rain/floorsink/ hub 16.60
P one: (3) �7g �2 / 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: S ) Page 2
Address: Primer 16.60
City / State/ZIP: Roof drain (commercial) 16.60
Phone:( ) Fax : :( )
Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E-mail:
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: x-1/11 (. I1.44� Water heater 16.60
Address: Other:
City /State/ZIP: Subtotal
Minimum permit fee: S72.50
Phone: (51 Ta-, Fax: ( ) Residential backflow minimum permit fee: $36.25 7o - b G
CCB Lic.: 55S9, i % Plumbing Lic. no.: Plan review (25 %ofpermit fee)
Authorized signature:
State surcharge (8% of permit fee) L�j i�G
TOTAL PERMIT FEE ! D , 3
Print name: /�¢�jrj ,Q� / .17Z--- Date: -27- p� 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 \Pennits\PLM- PermitApp.doc 12/30/05 4404616T(10/021COM/WEB)
PlumbinE Permit Application - City of Tigard .4
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - I ° 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 S10,000.00 and $1.54 for
Residential Back flow 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
Inspection of existing plumbing or each additional $ 100.00 or fraction thereof; to
specially requested inspections - per hour 72.50 and including $50,000.00.
$50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal: 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 (Future) Work Performed ❑ Any new commercial building.
Future 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 El Any new residential building containing three (3) or more
- Domestic dwelling units.
Drinking Fountain
Eye Wash El Any NFPA 13 -D multipurpose fire sprinkler system.
Floor Drain /sink 2" Submit 2 sets of plans with any 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 \Pennib\PLM- PermitApp.doc 07/06/05
CITY OF TIGARD
BUILDITIG DIVISION PERMIT #&7 _ 6)6 //,)_.
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: / g C l / �� / CLASS OF WORK:
SUBDIVISION: L T #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: 3- Pour Time ` d v
Code # Inspection Description Confirm # Contact # Message
OS
Corrections /Comments /Instructions:
(//j6 & .1
r
T ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
r
Inspector: Date: I Phone #: (503) 718-
� t'1,2‘
ALGiLLV
• ti J e remiah , Inc. ft
eri „ , 810E Main
t o Molalla, OR 97038 DATE Nis
', "' (503) 829 -7600 _ " 9'1 '\<
r.- Ilik t Dave s cell: (503) 209 -7641 NUMBER
:. Newberg (503) 538-8808
a;s Silverton (503) 873-7622
1-866- 939 -7600 CCB# 158543 DEQ# 38346
Complete System Installation
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TERMS: Net 10 Days. A service charge of 1 (18% per annum), $2.00 minimum will be applied to past due accounts.
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PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $
DATE CHARGES AND CREDITS BALANCE
ALANCE FORWARD I
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74144 PAY LAST AMOUNT
IN THIS COLUMN