Permit CITY TIGARD PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2003 -00102
I I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3126!03
SITE ADDRESS: 12500 SW BELL CT PARCEL: 2S104AA -00900
SUBDIVISION: BELLWOOD ZONING: R -4.5
BLOCK: LOT: 058 JURISDICTION: TIG
CLASS OF WORK: REP 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: 25 ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Replace approximately 25' of sewer service.
FEES
Owner:
Description Date Amount
OLSON, ROBERT I AND
SYLVIA A [PLUMB] Permit Fee 3/26/03 $72.50
12500 SW BELL CT [TAX] 8% State Tax 3/26/03 $5.80
TIGARD, OR 97223 Total $78.30
Phone :
Contractor:
RESCUE ROOTER
PO BOX 1728
WILSONVILLE, OR 97070 REQUIRED INSPECTIONS
Phone Sewer Inspection
hone : 685 685
Final Inspection
Reg #: LIC 127325
PLM 34 -168
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
'r-
/ r
ued By: k . 41/ , Permittee Signature:
Call (503) .39 -4175 by 7:00 P.M. for an inspection neede• he ne t business da„..„0/
Building Fixtures
Plumbii Permit Application / ,FOR OFFICE USE ONLY
Received S qi D � Plumbing � G� 10/OP-
Date/By: YO y: o O Permit No.:
Planning Approval Sewer
City of Tigard Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 Date/By: Permit No.:
Phone: 503- 639 -4171 Fax: 503 -598 -1960 Post - Review Land Use -
/ /u,� p9N! � t'`� Date/By: Case No.:
Internet: www.ci.tigard.or.us 6111_ � � Contact .10 ® See Page 2 for
24 -hour Inspection Request: 503- 639 -4175 W Name /Method: // IL!J. Supplemental Information.
t.a., g s �� g . - .�, i� � .� � . �'' ��i °» .' -,. :- �:...�- of :�:, :« �.. ., ..; �.. •aw.c`�° 'd'�.`'- `
a E , � : .4 �, ET,YfP C WORK;;:. *s r �.. ,�� 5: ;. > FEE, „�,SCHE MJLE (for spec►alninformation use i
❑ New construction ❑ Demolition Description I Qty. I Fee(ea) I Total
a Vi i j pNew & 2 fenly ireittigs ACM � , A e`
Cg Addltlon/alteration/replacement ❑ Other �,, , �(. : k! A� ty ) � , K
.. „ i ff . .,. mcludest100 for each,utili (c onnect i on
i:. CATEGORY OF CONSTRUCTION;: _ s
1 & 2-Family dwelling Commercial /Industrial SFR (l) bath 350.00
Y g ❑ SFR (2) bath 350
]Accessory Building ❑ Multi- Family SFR (3) bath 399.00
❑ Master Builder ❑ Other: Each additional bath/kitchen 45.00
M�14r.I - _ ...T a '" .. i Fire sprinkler - s ft.: Page 2
�� ����J,OBI'SI'I'E� INFORlY1?cTION and;L�OCATIO �:�� � P 9• . , g ^�.
Job site address: g'1.5/0 SW iS e (,( f T I -. �°, . s F,� ` ` t:,; _ . ;'Site iliilitieS ,.,.. r4a >,�.«� :. '""� } a' . a
Suite #: I Bldg. /Apt. #: Catch basin/area drain 16.60
Project Name: Drywell /leach line /trench drain 16.60
l Footing drain (no. linear ft.) Page 2
Cross 4. 1rectji to job site: Manufactured home utilities 110.00
' .e LL C 7- Manholes 16.60
Rain drain connector 16.60 A:4
Sanitary sewer (no. linear ft.) ' s Page 2 i'
Subdivision: Lot #: Storm sewer (no. linear ft.) Page 2
Water service linear ft.)
..���� .. _.. ,
.. ; a Page
Tax map/parcel #: ice (no 1 ear . a , m s DE � , w r Z.. Absorption valve 16.60
( r 01,ar e G.IA /9ha )/ 7 6 5 r u- e r Backflow preventer Page 2
"(J; 0 to, Backwater valve 16.60
/ Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
RI 1 ' <RUPERTW .OWNER i .. 4 -' TWO . ° „.. .. Ejectors /sump 16.60
tame S 7 1. v ; o 0 D LS G ✓'• Expansion tank 16.60
Address: 12. ' coo 5 )8r a r Fixture /sewer cap 16.60
City /State /Zip: Tr 1 ' 2-2.3 Floor drain/floor sink/hub 16.60
Garbage disposal 16.60
one: 61.0.2 5 C. Fax: Hose bib 16.60
APPLICANT . E '0 l&i.CONTAVCRWOIsE104 Ice maker 16.60
Name: e G k Aop i. e r . Interceptor /grease trap 16.60
Address: �_ a , 11, .ace Medical gas - value: $ Page 2
Primer 16.60
City /State /Zip: (A) ) t oN Vt
t 1! e as (1 CJ
Roof drain (commercial) 16.60
Phone: 615- el0 so Fax: 6 4f ' C (cry Sink/basin/lavatory 16.60
E -mail: Tub /shower /shower. pan 16.60
titSEARATAZRAMOOSMIOIM-ASMZWW S Urinal 16.60
Business Name: } e 5 e K P Ko C y� r Water closet 16.60
n Water heater 16.60
Address: Y -• 0 . kl Y( 'Z ,S_ Other:
City /State /Zip: Wit- 5 I`ll Other:
Phone: t I/ 5' %'r/ co Fax: Co f 5% 9 i ir 5 z; ama mi<.aqupiumbiho rmtt >Fees ..: ..5m,
Subtotal $
CCB Lic. 4j 1 2 ' PL .,1 b. L1c. #: LI 46: p Minimum Permit Fee $72.50 $ 50
Authorized l Backflow Minimum Fee $36.25
Signatu : "�I� Residential
, 24 "5 Plan Review (25% of Permit Fee) $ .
O y .+o ✓ / / �S e State Surcharge (8% of Permit Fee) $ S ' ISO
(P ease print name)
TOTAL PERMIT FEE $
Notice: This permit application expires if a permit is not obtained within All new commercial buildings require 2 sets of plans with isometric or
180 days after it has been accepted as complete. riser diagram for plan review.
*Fee methodology set by Tri- County Building Industry Service Board.
i:\Dsts\Permit Forms\PlmPermitApp.doc 01/03 #78 '3 v
Plumbing Permit Application - City of Tigard . ._ „ -
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
44. PC i,tv 1 61:0#k ,:$4,417:,09otage: -:,..1 : --,,,,, , : :
Footing drain - 1s 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 Niriiitiaii::, ,:'": fP.SiiIiiMe:;
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
x 0,0.,M -! 104
additional $100.00 or fraction thereof, to and
We'VER.014,074Strtital7,7,,-. §1 ; .:.r TIAtiri 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, tq
(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 $50,000.00.
specially requested inspections - per hour 72.50
$50,001.00 and lip' ' - - .$742.00 for the $50,000.00 and $1.20 for
Subtotal: each additional $100.00 or fraction thereof.
• 0 .,
..Z. r ' • ..
Fixture Work:
Are you capping, moving or replacing existing fixtures? If
"yes", please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*.
oiiIiiiiiy!iiF(fliiiiiii)i8y4WP:Eiaiirileir4) t Comments regarding fixture work: . .
FTi;:,,l',.. ', Fek•idtil ';'i !a%c4,:,-.1 . , -" ",... • : 'k ". ,,
R::;::- Moved Wkiiriihgg ftdapPat: ...
Baptistry/Font
Bath -Tub/Shower
-Jacuzzi/Whirlpool .
Car Wash -Each Stall
-Drive Thru .. A ' • '‘ . ,
.
Cuspidor/Water Aspirator .
, , .
Dishwasher -Commercial . .
•
.. .. . •
-Domestic . .
Drinking Fountain . .
Eye Wash , .
Floor Drain/sink - 2"
1 -, .. , ,. .. 2. •,- , ,
' " . - . • , ' .
Car Wash Drain
*Note: if the fixture work under this permit 'results in an
Garbage -Domestic
increase of-sewer EDUs,'a'sevVerpermit will be issued and
Disposal -Commercial
-Industrial fees as . iessed f6r the sewer increase must be paid before the
Ice Mach./Refrig. Drains - . plumbing permit can be issued.
Oil Separator (Gas Station)
Rec. Vehicle Dump Station , ,
Shower -Gang
-Stall .
Sink -Bar/Lavatory . . •
. , • -
-Bradley . , . . - . . .
. . .
-Commercial .• . - , .. ....
-Service '
Swimming Pool Filter
Washer - Clothes . .
p .
-.. . . . .
. Water Extractor .
Water Closet - Toilet ..
Urinal.' ,
Other Fixtures:
i:\Dsts\Permit Forms \PIrnPermitAppPg2.doc 01/03
Case Activity Listing 11/15/2004
12:42:15PM
TIDEMARK Case #: PLM2003 -00102
COMPUTER SYSTEMS, INC.
u
PLMA003 Application received 3/26/2003 None DONE DEB 3/26/2003
RCP
PLMA005 Create Permit 3/26/2003 None DONE DEB 3/26/2003
RCP
PLMA705 Sewer Inspection 4/3/2003 None PASS MRS 4/3/2003
MRS
PLMA799 Final Inspection 4/3/2003 None PASS MRS 4/3/2003
MRS
PLMA050 (F) Issue permit 3/26/2003 None DONE DEB 3/26/2003
RCP
PLMA711 Water Service Insp 4/3/2003 None PASS MRS 4/3/2003
MRS
PLMA055 (F) Reprint Permit 4/1/2003 None DONE BLD 4/1/2003 added water service to permit
BLD
PLMA800 Case Finaled 4/3/2003 None PASS MRS 4/3/2003
MRS
Page 1 of 1 CaseActivity..rpt