Permit .t _ IR CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2008 -00377
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 9/25/2008
PARCEL: 2S103BA - 00105
SITE ADDRESS: 11830 SW ANN ST ZONING: R -4.5
SUBDIVISION: LERON HEIGHTS LOT: 005 JURISDICTION: TIG
PROJECT: PROCTOR
Project Description: Connecting existing house to sewer. Septic tank to be pumped and filled. Reimbursement district
#40. Fees paid 9/25/2008.
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:
TUB /SHOWERS: SEWER LINE: 100 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
PATRICK PROCTOR
11830 SW ANN ST Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 9/25/2008 $72.50
[TAX] 12% State Surch 9/25/2008 $8.70
Phone : 503 -524 -2237 Total $81.20
Contractor:
OWNER
REQUIRED ITEMS AND REPORTS
Contact # : pRl
Reg #:
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 -0 - 100. You may ob ain copies of
these rules or direct questions to OUNC b ' • •699 or 1.800.332.2344.
: � / �/ Pe rmittee Signature:/ / 4
Issued By
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.
Plumbing Permit Application
Buildin g Fixtures id t) 0 y I O l l It I I `--1 O's ii
°
City of Tigard D are/B Permit �i'� /1 111 1i.
al 13125 SW Hall Blvd., Tigard, O ', Plan Review
c `-
= Phone: 503.639.4171 Fax: 503. 8. 960 Q ao Other Permit No. 3 c. _ �� ,/
6 3c,
T 1 G A K t7 Inspection Line: 503.639.4175 C 3 \-' �� �l hy' Re ad y B y : Ii B See Page 2 for
Internet: www.tigard- or.gov 'R � ,•,1� Notified Method: Supplemental Information
TYPE OF WORK G `�� FEE* SCHEDULE
❑ New construction Cl Dgi dolition For special information use checklist.
Description I Qty. I Ea. I 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- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building I=I Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
. Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: ) / f Si.) / S Catch basin or area drain 16.60
City /State /ZIP: -- --r-i g { d by g 7 2. 3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.:. --_ > I Project name: /2/7)(710(--- " y��/2/7)(710(--- Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: F , / Page 2 Sc:�
Storm sewer (no. linear ft.: Page 2
Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve l 16.60
DESCRIPTION OF WORK Backflow preventer Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: P 74,' /ti e,..
r �}^ Expansion tank 16.60
Address: Sa q s' q 6e 1 . Fixture/sewer cap 16.60
City /State /ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
❑ APPLICANT 1=1 CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: / 5ye, 0 _4 /, > t_,_ Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State /ZIP: Roof drain (commercial) 16.60
Sink/basin/lavatory 16.60
Phone: ( ) I Fax: ( ) Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: 54 ( et 5 cl ,4_, ie.-4- Water heater 16.60
Address: 11 ) SLf ,Anr Se.,_ Other:
Subtotal
City/State/ZIP: '754 e. r 0)2 9? � .9 3
Minimum permit fee: $72.50
Phone: (5.n7) 5,Qir , a ?37 Fax: ( .- Residential backflow minimum permit fee: $36.2577? '56
CCB Lic.: PI bing Lic. no.: Plan review (25% of permit fee)
State surcharge (12% of permit fee) S, 70
Authorized signature: ,t�j4 , . / TOTAL PERMIT FEE N
Print name: ,t ,. p ,/,,,„- Date: g ,,2 5. oT 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 \Permits\PLMF- PermitApp. 12/27/06 440- 4616T(I0/02/COM/WEB)
t 1 7 1 / ,
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information .
Fee Schedule: Residential Fire Suppression Systems:
Safe`lJtil ties) . _ Qty. F¢c (ea >' : STOP! Square,Footage: .Permit Fee: •
,
Footing drain - 1' 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
Qt >; ,Fee ea ,' "Total additional $100.00 or fraction thereof, to and
Fixture Or'Itema.n < . )= including $10,000.00.
Commercial Back Flow Prevention Device 46.40 $10,001 00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
Residential Backflow 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
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or
and including 00 ot the first 5 00.
specially requested inspections - per hour 72 50 $50 and up $742.00 for the first $50,000.00 and $1.20 for
Subtotal:
each additional $100.00 or fraction thereof.
Commercial Fixture Work: : Plan Review, for Plumbing Installations,_
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees * . ❑ Any new commercial building with water service 2" and
Quantity y. (Fixture)` Work Performed greater, except systems designed and stamped by licensed
-
Fistur¢ Type: � - . Replace., en g ineer.
Previous _ . Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure
Baptistry/Font as defined in OAR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi /Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040.
-Drive Thru
Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain " Isometric Or RlSer Diagram - _
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
-4"
Car Wash Drain
Garbage - Domestic Comments regarding fixture work:
Disposal - Commercial
- Industrial
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the
Swimming Pool Filter plumbing permit can be issued.
Washer - Clothes
Water Extractor
Water Closet - Toilet
Urinal
Other Fixtures:
i:\Building\Permits\PLM- PermitApp.doc 12/27/06
,_ �= IIIII II I III III I IIII II
Date 10/07/08
Scheduled 10/07/08 Septic C.O.D. •
River City EnvironmentaLI Inc, Work Order # W082317
503- 252 -6144 Complete Industrial
P.O. Box 30087 Waste Removal
Salem 503 - 363 -2464 Vancouver 360 - 896 -5256
Septic
Portland, OR 97294 www.rivercityusa.com Sump Line Cleaning
OR CCB# 147355 WA CCB# RIVERCR981BT
� 4 Site Infor matlQn � t ..,
1 .` . .,,. . t � � .d , i � }�§'r% S�x .Ffi}n�h AO.5 ;'. "�PA r, W a . F ""k . ri .
Tiffany Proctor Tiffany Proctor
• 11830 SW Ann St 11830 SW Ann St Tigard
Tigard, OR 97223
Contact: Tiffany 503 -524 -2237
503- 524 -2237 PO#
r , TY pe i � .. Descn ption " of Wor , ' a Unitsland'Ptice - if lr
Septic. Service @' •
Notes COD, lid exposed 2 lids for this tank, pumping for decommission, CAII Tiffan when on t
9 g _
. _� -- - y the
way 503- 524 -2237, she will be there all day today, tomorrow she will be home until 11 :00AIK
.
OU c (S i Total Charges „
L — _ -- '
River City Environmental, Inc. is in no way responsible for damage to any vehicles, personal or real property.3''gr . j^ _ p G
Terms: Net 10 days. 1.5% per month will be charged on past due accounts (18% per annum). C45 n t
Terms and Conditions The Right to Lien (u r
The customer agrees to pay all invoices arising out of services, and any other special services herein within 10 days. '�✓
The customer agrees to pay such extra and overtime charges as may be invoiced from time to time for services rendered, over and above the normal servicing
schedule, on behalf of the customer.
The customer agrees to assume responsibility damage to customer's real or personal property arising from services which take place
on customer's premises, where the drivers and vehicles of River City Environmental have been instructed to enter.
This includes, but is not limited to driveways, trees, power lines or poles and building structures.
If River City Environmental, Inc. finds it necessary to add liquid to the tank on jobsite, customer will be charged for the additional gallonage resulting from these condidtions. .
Customer agrees to reimburse River City Environmental, Inc. for all reasonable attorney's fees court costs and other expense incurred by said company to enforce
collection or to serve their rights under this agreement.
If this work order is not contested in writing within 10 days the full amount is considered due and payable.
Customer agrees to the above conditions. A fax on the work order is considered an original. Redeemable in Multnomah County
Check # Visa MC Amex Card # Exp Date Vcode
Work Authorized by i. A .1,3 A V,_, -t D _ ,/ . /_
��� � ,t) G �, a
Service Tech #1, �> ! -`fi=r 0 v Serv Tech #2 Date'f-\ 1.._ /� Time
4,
M f t Y! Ake G i t y : \6LYTJ '1' }.M t
CITY OF TIGARD
BUILDING DIVISION
PERMIT #:
PLM2008-00377
9/25/2008
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639-4171 a#041111-
Inspection Requests (24 Hrs.'): (503) 639-4175 AO. ■ L
INSPECTION WORKSHEET FOR . ' DATE: TIME: PAGE:
10/14/2008 7:00AM 18
SITE ADDRESS: CLASS OF WORK:
11830 SW ANN , ST
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME: LERON HEIGHTS 005
PROCTOR
DESCRIPTION:
Connecting existing house to sewer. Septic tank to be pumped and filled. Reimbursement district
#40. Fees paid 9/25/2008.
OWNER: PHONE #: 503 PROCTOR, PATRICK
CONTRACTOR: PHONE #:
OWNER
Inspection Request Scheduled For: Date: Pour Time:
10/14/2008
Code # Inspection Description Confirm # Contact # Message
399 Plumbing final 076664.01 503-7899403
Corrections/Comments/Instructions:
k ■
PASS LII PARTIAL APPROVAL ri CANCEL fl NO ACCESS
FAIL I I CALL FOR INSPECTION ADDITIONAL FEES ASSESSED
Inspector: 0 1, )`A Date: P Phone #: (503) 718-
. „ ,
CITY OF TIGARD • . — Pa
BUILDING DIVISION PERMIT #:aL2 p S —O0377
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 aNNypulpj +j�l`
Inspection Requests (24 Hrs.): (503) 639 -4175 .'
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: 11 Q3 U s a 1 CLASS OF WORK:
SUBDIVISION: I U LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: / p --3 — O 5' Pour Time:
Code # Inspection e Description Confirm # Contact # Message
9
3 g c i 071e301 -01 S7>3— `1 59— 9Y03
Corrections /Comments /Instructions: �z? -u I b 0 P I7
H i' .T►_44 ,.k. ¶D (1t .`, 2 C' t t, ® �� vwc. w✓ e
C o 1 -1-,t Co i n.rc fis 1 t ri d✓ P , w.,la i P U, li ` �
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1 _.P . A IP `oc l i i. pcv-t -ol ckk-�c �.1 j r<u✓�e a� �C 1 �! t
PASS PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: ■11.A...,► \' V�...•� Date: I (.3 ID Q) Phone #: (503) 718-