Permit •
CITY TIGARD PLUMBING PERMIT
, DEVELOPMENT SERVICES PERMIT #: PLM2001 -00618
• ' I 1 3125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/26/01
SITE ADDRESS: 12660 SW 121ST AVE PARCEL: 2S1036D -01300
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
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: 70 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Connect existing residence to newly installed sewer lateral. Septic tank must be pumped, filled and inspected.
Reimbursement district fee was paid.
FEES
Owner:
Type By Date Amount Receipt
BERGQUIST, R KELLY PRMT CTR 11/26/01 $72.50 27200100000
MERRILL M 5PCT CTR 11/26/01 $5.80 27200100000
12660 SW 121ST
TIGARD, OR 97223 Total $78.30
Phone 1:
Contractor:
TED MCBEE EXCAVATING INC
11428 NE SCHUYLER
PORTLAND, OR 97220 REQUIRED INSPECTIONS
Phone 1: 939 -5246 Sewer Inspection
Reg #: LIC 110314 Final Inspection
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 ► ay obtal .opies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issu:d By: I • gi / ' � A ^ 4 1 oL/ Permittee Signature: ,�`�\
Call (503)_ • • -4175 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application
Date received: // e 94, N Permit no.: ti/ —ec* /g
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: Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
r. 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi- family ❑ Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: ) 9 , , -J F \ c 'A i ,' 1 ') \ 37 L Descri i tion I . 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: IBlock: I Subdivision: SFR (2) bath
Project name: ‘ (3) bath
City /county: r I ZIP: Each additional bath/kitchen
Desc 'ption and I a 'on of w i r on pr ises: (c . 'A "it, Site utilities:
- ° 1, ►!._. ) . "a Em ,,,„;„ Catch basin/area drain
Est. dat- of completion/inspection: hbn wa UMW Drywells/leach line/trench drain
PLUMBING ('ONTRACTOIZ Footing drain (no. lin. ft.)
: a � ".!c7 Manufactured home utilities
Business name
c \� K� \ V ` ct , Manholes
Address: \ l ‘-\ 29 'JJ n� C -1 ' ° t ' Rain drain connector
City: R� I State: I ZIP : Sanitary sewer (no. lin. ft.) 70
Phonet? ) .-05 Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: o. ^
1 1 S I Plumb. bus. reg. no: Water service (no. lin. ft.)
! 1
City/metro he. no.: �n Fixture or item:
Absorption valve
Contractor's representative signature:, ,_ Back flow preventer
Print name: % ) •■ . Date: -, t ~1 Backwater valve •
('ONTA(I' PERSON Basins/lavatory
Name: L ►1 \7......• • Clothes washer
Address: Dishwasher
Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: ' - x' -- '' Fax: E -mail: Expansion tank
OWNER Fixture/sewer cap
Name (print): . „� Floor drains/floor sinks/hub
�� �( IYAy{ ti. Garbage disposal
Mailing address: f' 1 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:
Phone: I Fax: 1E-mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $
Notice: This permit application
❑ Visa ❑ MasterCard Plan review (at %) $
Credit card number: / / expires if a permit is not obtained State surcharge (8 %) .... $
Expires within 180 da after it has been TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount
4.40-4616 (6K10/COM)
PLUMBING PERMIT FEES:
• 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 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
Tub or Tub /Shower
Hose Bibs 16.60 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 Backfow
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
CITY OF TIGARD BUILDING INSPECTION DIVISION MST '
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP
Date Requested / / 3 � AM PM BLD
Location , Z Co (Q C /.?-/ 1 - i - -- Suite / / MEC
7
Contact Person Ph 5 (
2 7 4 , PLM 2- / D) 4:1 e s>
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access: -re--- FPS
Foundation ��11 p
Ftg Drain � • ` (,JAI-" `'` �' 1 L SGN
Crawl Drain Inspection Notes: J 3 L A 9 7777 Slab C� SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing / T
Drywall on
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling ( 77
Roof
Misc:
Final
PASS PART FAIL -
PLUMBING
Post & Beam
Under Slab
Top Out
Water Service
unitary ew
Rain Drains l"
iirwo
PART FAIL
MECHANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ I 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
Approach /Sidewalk Date / � , InspectorY/ L e Ext
Other
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
. .
invoice
GRUF ID'S SEPTIC SERVICE
. ,dam. -- e'�
Name / el �' fi ... .2- C C-WS t Date // -_ ?- 0 I
Address / 6 t � .r. t r ( -"""' Phone i':7
City / /7 4- r2. I Initial On Acct.
State C � 4- - Zip Code / ' l 1
Price Amount
t 4:_ee,-/ t-1) 6f; 7.4 /.z. 5.c.,,,,61 fe c.7 14") fe....
2 -3 i1 b0 : dk ENT . - - --0t-
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\ D r �. ? J
(..?"4/-. (63 f.:9 1
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NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING i
• A service charge of 1.5% will be levied on all past due accounts. Total: -,..,0 '''.
• Returned check fee is $20.00.
• In case suit, action or arbitration is instituted by either party for breach or to enforce any
provisions herein, the court shall award reasonable attorneys fees and actual costs to the
prevailing party at trial or arbitration, or upon any appeal taken therefrom.
--- -- — Approval ff
By: , (y c-
Customer Sig'natutr
��an� You P.O. BOX 1136 • Canby, OR 97013 DEQ# 37464
(503) 263 -2087 or (503) 632 -6138 CCB# 104320