Permit • CITY OF TIGARD SEWER CONNECTION PERMIT
I , DEVELOPMENT SERVICES PERMIT #: SWR2001 - 00277
All I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/5/01
SITE ADDRESS; 13760 SW 121ST AVE PARCEL: 2S103CC - 00600
SUBDIVISION: COLONIAL VIEW ZONING: R - 4.5
BLOCK: LOT: 001 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Reimbursement District #20 sewer connection. Plumbing permit required.
Owner:
FEES
ERDT, DONALD D
DOROTHY P Type By Date Amount Receipt
13760 SW 121ST PRMT CTR 10/5/01 $2,300.00 27200100000
TIGARD, OR 97223 INSP CTR 10/5/01 $35.00 27200100000
Phone: Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires
180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not
guarantee the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer
shall prospect 3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and
Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted
by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
i C ,,o-
Issued by: f E Permittee Signature: c' 4. e (� / , r
Call (503) 9 -4175 by 7:00 P.M. for an inspection needed the next business day
alt, Plumbing Permit Application
Date received: Permit no.:
b' � I Tigard
_ Building � Ci `J of b gar Sewer ermit no.: p permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223 p a Ol g p
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: D 0 a' 77 Expire date:
Fax: (503) 598 -1960 Date issued: By: 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 ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: 1 3760 5 , w r [ 2.f .k-- Description Qty. Fee(ea.) Total
Bldg. no.: l 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: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: r� C5�i fL 1/14 13 / /✓ L Manholes
Address: Rain drain connector
City: I State: 'ZIP: Sanitary sewer (no. lin. ft.)
Phone: I Fax: 1E-mail: Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Water service (no. lin. ft.)
City/metro lic. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: Date: Backwater valve
CONTACT PERSON Basins/lavatory
a V r Clothes washer
Name: Oit/ff < (� �� Dishwasher
Address: / 3 ?(p 0 s ) (2! 116._ Drinking fountain(s)
City: TO 6 4 2 0 I State: 0 d I ZIP: 9 71 - 2 - 3 Ejectors/sump
Phone: 7 (; ; -..) - s'9 - Fax: E -mail: Expansion tank
OWNER Fixture/sewer cap
Name (print): /I .L0 q�D 0 «D They k' / P
Floor ge d sinks/hub
pa
Garbage disposal
Mailing address: /3 7G o 5 w / 24 s _t/AI// Hose bibb
City: - 6, R 0 I State: e R I ZIP: 9 72 2 - 3 Ice maker
Phone:..) -3 s s � Fax: 1E-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: 9g 7,-6 ,Q. f (-- Date: /0 —1-- 0 / Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: 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. Mlnlmum fee $
Notice: This permit application Plan review (at %
O Visa 0 MasterCard expires if a permit is not obtained ( %) $
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440 -4616 (6i00/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
Urinal
Other Fixtures (Specify) 16.60 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
Other Fixtures
Water Service - each additional 200' 46.40 (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
/ a
1
CITY OF TIGARD BUILDING INSPECTION DIVISION w
MST
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP
Date Requested /a —/( AM BLD
Location / 7374 0 /c,2- ..Q 4-?--_- Suite MEC
Contact Person 4 X 0 — , 2 - , Ph . 73 J ,s PLM ,DO ( Z .6 S
Contractor Ph c siM ZOO /-Qo2. i 7
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access: (-
Foundation s ,{/ FPS
Ftg Drain `'J 4ft 1 2 D / 2 / ✓ SGN
Crawl Drain Inspection Notes:
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
( 7 -.--..----------- f• )
Fire Alarm
Susp'd Ceiling 72
Roof
Misc: '
Final
PASS PART FAIL
PLUMBING -----------
Post & Beam `
Under Slab
Top Out
Water Service
aril ary ewer
'n Drains
' ASS PART FAIL
IItHANICAL
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 [ ] 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 /' L 2- r 7 U Ext
x
Other Date /0 — / ` d / Inspecto
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
..
STEVE MCBEE PAGE 01
• • _
12/29/1995 22:69 5032515428
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NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING
____________
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• A service charge of 1.5% will be levied on all past due accounts. Total!
,..2 2 L.J
• 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
Sy:
Customer Signature
T
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P0. BOX 1136 • CIRby OR P7013
(503) 2 63-2087 or (503) 632.6138 DEO# AM
cc* 10432 I