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Permit
CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit #: PLM2011 -00209 Date Issued: 07/01/2011 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Parcel: 2S110CB09800 Jurisdiction: Tigard Site address: 15227 SW ARLINGTON TER Project: Arlington Heights No. 3, Lot 86 Subdivision: ARLINGTON HEIGHTS NO. 3 Lot: 86 Project Description: Backflow for irrigation. Contractor: SAN FRANCISCO LANDSCAPING & MAINTENANCE Owner: SKYLINE HOMES & DESIGN 19297 ALLISON RD NE 6021 SE MILWAUKIE AVE HUBBARD, OR 97032 PORTLAND, OR 97202 P PHONE: 503 - 235 -3810 HONE: 503 - 957 -7604 FAX: FEES Quantity Description Date Amount 1 ea Backflow Preventer 07/01/2011 $31.27 Specifics: 1 12% State Surcharge - 07/01/2011 $8.70 Plumbing Type of Use: SF 41 ea Minimum Fee Adjustment - 07/01/2011 $41.23 Plumbing Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $81.20 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. lab Issued By: Permittee Signature: (� Call 503/.4175 by 7:00 a.m. for the next available inspection date. 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 Application Building Fixtures FOR OFFICE USE ONLY Received / City of Tigard II Date/By: r �� 7! /� Permit No .: o aDI i a.o' l v 13125 SW Hall Blvd., Tigard, OR 97233 "� Phone: 503.718.2439 Fax: 503. 9 \ \ Plan Review � Date/By: Other Permit No.: M5 . 4 . c , 0 _ (1 O(D 9 ✓ ® Y. W Inspection Line: 503.639.4175 0s Date Ready/By: Juris: See Page 2 for TIGARD Internet: www.tigard- or.gov . , c Supplemental upplemental Information TYPE OF WORK J 0s .FEE* SCHEDULE ,R New construction ❑ Dem :CO' For special information use checklist � C Description - I Qty. i Ea. I Total ❑ Addition/alteration/replacement ❑ Othel New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 312.70 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78 SFR (3) bath 500.32 ❑ Accessory building ❑ Multi- family Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: \ 5 7, 1 S� Q - \ i In , Y ,kG.e Catch basin or area drain 18.76 City/State/ZIP: ^ _� (� � .-t Drywell, leach line, or trench drain 18.76 Y p &r tl O '� ` 22 Footing drain (no. linear ft.: ) Page 2 Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Water service (no. linear ft.: _) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map /parcel no.: Backflow preventer I, 31.27 3 ), )..-'7 DESCRIPTION OF WORK Backwater valve 12.51 r Clothes washer 25.02 'zkQ- tc- .F l4 ,9-1k-e c'0 Tr SF i . v.nekif &- Dishwasher 25.02 1 ''.> k-- -%,� ■ Drinking fountain 25.02 Ejectors /sump 25.02 ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 Name: Fixture /sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 25.02 City /State /ZIP: Hose bib 25.02 Phone: ( ) Fax: ( ) Ice maker 12.51 ❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02 Business name: Medical gas (vali a ) Page 2 Primer 12.51 Contact name: Roof drain (commercial) 12.51 Address: Sink/basin/lavatory 25.02 City /State /ZIP: Solar units (potable water) 62.54 Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51 E -mail: Urinal 25.02 CONTRACTOR � Water closet 25.02 Water heater 37:52 Business name: 5 a v\ „a_,�,-, eJ 5 ..C� �� 3 r o. �,� fr. Q - � . Water piping/DWV 56.29 Address: ( ZG `l (� 11 h 5� W` J 1 - t - ) Other: 25.02 City /State /ZIP: 1_4 06(©a fd n 12- C ld2 '7 Subtotal Phone: (C;O 2) C c -, --- /G.0 4 Fax: ( ) Minimum permit fee: $72.50 72, s-0 CCB Lic.: C-3 4 1r7/3 l y Plumbing Lic. no.: Plan review (25% of permit fee) `' State surcharge (12% of permit fee) . F. - 70 Authorized signature: k.A-) 0A- _„,- - TOTAL PERMIT FEE ri , )-() ! t Date: This permit application expires if a permit is not obtained within 180 days Print name: ir�ti. L L-J U t.�� (' (, after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. I: \ Buildineermits \PLMU- PermitApp.doc 10/01/09 440- 4616T(l0 /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' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer - 1st 100' 62.54 7,201 and greater $327.54 Sewer - each additional 100' 37.52 Water Service - 1st 100' 62.54 Medical Gas Systems: Water Service - each additional 100' 37.52 Valuation: Permit Fee: Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to p and including $10,000.00. Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge- 1/2 hour) and including $25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge- 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees * . Quantity by Fixture Type Plan Review for Plumbing Installations Fixture Type for Replace/ Work Performed: Capped Added Relocate Plan review is required for any of the following. Baptistry/Font Please check all that apply. Bath Tub /Shower ❑ Any new commercial building with water service 2" and Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed Car Wash -Each Stall engineer. -Drive Thru ❑ New exterior plumbing site utilities for any complex structure Cuspidor /Water Aspirator as defined in OAR918- 780 -0040. Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities. - Domestic ❑ Any multipurpose fire sprinkler system. Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040. Eye Wash Floor Drain/sink - 2" Submit 2 sets of plans with any of the above. -3" Isometric or Riser Diagram Car Wash Drain ❑ Isometric or riser diagram is required for new buildings - Domestic non - food s g q g Disposal - Domestic - food related that meet the qualifications above. - Commercial -food related - Industrial -food related Ice Mach. /Refrig. Drains Oil Separator (Gas Station) Comments regarding fixture work: Rec. Vehicle Dump Station Shower -Gang -Stall Sink/Lav - Non -food related - Bradley - Commercial -food related - Service Swimming Pool Filter *Note: If the fixture work under this permit results in an Washer - Clothes increase of sewer EDUs, a sewer permit will be issued and Water Extractor p Water Closet - Toilet fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. Other Fixtures: I:\ Building \Permits\PLMF - PermitApp.doc 02/24/2011 2 WP 1202667 . ea . - EXISNG a NE PNWS-AWWA B ASSEMBLY TEST REPORT 0 REMO ED -- - PROPERTY ( ❑ REPLACEMENT '" `OWNER: L U ,, "serti .k �� C St C� PHONE: MAILING L 3 . 9 .SctJ Y Vi r ADDRFSS: R°` „1v q C- �� \ • CITY / 1 4 \ clod 11 C STATE i ZIP 1 3 -Q- 4 1 ASSEMBLY ADDRESS: -S C/ W..L cis al oV J STREET ❑ R.P.B.A. IJ D.C.V.A. ❑ R.P.D.A C� ❑ D.C.D.A. ❑ P.V.B.A. ❑ S.V.B.A. ❑0 A.V.B. ❑ AIR GAP SIZE: I I ) 1.2 I Q MAKE: T L. MODEL: g c WATER l 1 ] PURPURVEYOR: na 1((� NUM SERIAL BER: / f � r / t- / L/ R LOCATION: -0 (A.1 Q�c� Y"� LOCATION: • REDUCED PRESSURE .ASSEMBLY P.V.B.A. / S.V.B.A • INITIAL T MI CHECK V DOUBLZ :clig K `r� AIR �:�.: CHECK PASSED PRESS DROP (A)1 CHECK 9 INLET FAILED ❑ INITIAL RELIEF VALVE TIGIIT d (B) 2• I OPENED AT: PRESS DROP OPENED AT TEST MIN 2 PSID ( re PSID D TE: RESULTS BUFFER LEAKED PSID PSID / / ` /41 Oil A - B = I .CHECK N2 MIN 3 PSI RELIEF VALVE (TIGHT R DID NOT FAILED SYST4M PASS ❑ FAIL ❑ 'LEAKED❑ PPSID D //,' OPEN ❑ ❑ PSI /� COMMENTS REPAIRS AND /OR PARTS i c REDUCED PRESSURE ASSEMBLY P.V.B.A. /S.V.B.A. AFTER REPAIRS al CHECK t V D:C A: #� <, , s w TEST PRESS DROP (A) ( CHECK #1 DATE: •RELIEF I OPENED AT PRESS DROP / AFTER OPENED (B) T IGHT ❑ PSID REPAIRS '®1 IMO BUFFER R nsra (TIGHT ❑ PSID PSID PSID PASSED ❑ m+ IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE TESTER CERTIFIES THAT THE ASSEMBLY HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE RULES AND REGULAT NS OF THE WATER SYSTEM, AND STATE REGULATIONS. GAUGE CALIBRATION DATE I Q It 1 DETECTOR METER READING C a,-S TESTER SIGNATURE A 1 (1I t - CAL IA' 0 ( y ik TESTERS NAME PRINTED ,!{' r Y 1 � � `' s � TESTERS ADDRESS r '8 �^ GJ PHONE M P. c7 ?ill, 1836 6Y� s 4,�. r... 0./ g o 3 v COMPANY NAME - REPORT RECEIVED BY: I SERVICE RESTORED (REPRESENTATIVE OF OWNER) • • _ --,r14-% WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester Copy