Permit CIT OF TIGARD PLUMBING PERMIT
'iii r DEVELOPMENT SERVICES PERMIT #: PLM2001 -00621
_.��! 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/27/01
SITE ADDRESS: 12660 SW 121ST AVE PARCEL: 2S103BD -01300
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
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: 1
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Reverse plumbing and connecting to sewer line.
FEES
Owner:
Type By Date Amount Receipt
BERGQUIST, R KELLY PRMT CTR 11/27/01 $72.50 27200100000
L M 5PCT CTR 11/27/01 $5.80 27200100000
12660 S
12660 SW 121ST
TIGARD, OR 97223 Total $78.30
Phone 1:
Contractor:
LARRY CAMERON PLUMBING
1812 SE 158TH AVE
PORTLAND, OR 97233 REQUIRED INSPECTIONS
Phone 1: 503 - 256 -2705 Misc. Inspection
Reg #: LIC 49792 Final Inspection
PLM 26 -366PB
E XPIRED
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: 441IGtGt�iJIC�(�/ Permittee Signature: A A. —farm-
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed next bu n if day
V
Plumbing Permit Application
Date received:I I _,') — 01 Permit no.: - 1 y : r, % l
: ..F��., ; City of Tigard
�� 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"jb Receipt no.:
Land use approval: Case file no.: Payment type
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi family ❑ Tenant improvement
❑ New construction 0, • ddition/alteration /replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: 1 740 (p 0 . J 21 Description Qty. Fee (ea.) Total
Bldg. no.: 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: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
T2 44- i /J 02 rs' UY1'Z SO L- Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Business name: ccc��� Manufactured home utilities
ft (r C C7L-Vti Manholes
Addre lo Z I (a S� J� .0•-) i I Rain drain connector
City: jz,(�jevi.49 +S et tate:bYt 'ZIP: q 7 - 2,14. - , Sanitary sewer (no. lin. ft.)
Phone: I Fax: 1E-mail: 1 7 Storm sewer (no. lin. ft.)
CCB no.: r 7e/ 2 — f o % I Plumb. bus. reg. no j 6 (5/ Water service (no. lin. ft.)
City/metro lic. no.: Fixture or item:
representative si atu ' •': i / Absorption valve
Contractor's re
p -� - !� r - � Back flow preventer
•
Print name: - y J 1,a e :) -.2-7-4 Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: 'State: 'ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print): Floor drains/floor sinks/hub
Mailing address: Garbage disposal
Hose bibb
City: I State: I ZIP: Ice maker
Phone: I 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
Name: Urinal
Address: Water closet
Water heater _
City: I State: I ZIP: Other: ;<',,c2 --,: _ ,
Phone: I Fax: 1E-mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $ • Std
❑ Visa ❑ MasterCard Plan review (at %) $ _
Credit card number: / " expires within 180 a permit not beeen nd State surcharge (8 %) $ J ' gv
Expires days after it has s be
accepted as complete.
TOTAL $ 715.0
'3
Name of cardholder as shown on credit card p
$ ,J
Cardholder signature Amount
440-4616 (6R)O/COM)
PLUMBING PERMIT FEES: 44 •
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 (2) 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
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 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavatory
Hose Bibs 16.60 Tub or Tub /Shower
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 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain, single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
* SUBTOTAL
8% STATE SURCHARGE
* *PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
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.
is \dsts \forms \plm- fees.doc 08/29/01