Loading...
Permit - a 41 C ITY OF TIGARD PLUMBING PERMIT I DEVELOPMENT SERVICES PERMIT #: PLM2003 -00359 ,�I DATE ISSUED: 8/27/03 13125 SW H BI d Tigard, OR 97223 (503) 639 -4171 .- 28.5&SW GRANT ST PARCEL: 2S102CB -00100 SITE ADDRESS: SUBDIVISION: NORTH TIGARDVILLE ADDITION ZONING: R -12 BLOCK: LOT: 041 JURISDICTION: TIG CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HOME SPACES: TYPE OF USE: COM WASHING MACH: BACKFLOW PREVNTRS: OCCUPANCY GRP: El 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: 1,520 ft WATER CLOSETS: WATER LINE: 100 ft DISHWASHERS: RAIN DRAIN: 100 ft Remarks: Plumbing underslab only for new school building, setting of fixtures is to be done under separate permit. FEES Owner: Description Date Amount TIGARD - TUALATIN SCHOOL DISTRICT #23 6960 SW SANDBURG RD [PLUMB] Permit Fee 8/27/03 $953.80 TIGARD, OR 97223 [PLMPLN] Plan Review 8/27/03 $238.45 [TAX] 8% State Tax 8/27/03 $76.31 Phone : Total $1,268.56 Contractor: POWER PLUMBING CO PO BOX 19418 PORTLAND, OR 97280 REQUIRED INSPECTIONS Phone : 503 244 1900 Sewer Inspection Water Line Insp Reg #: LIC 52378 Water Service Insp PLM 34 - 150PB Underfloor /Underslab Storm Drain Insp Final Inspection This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Issued By: I(j../7/L � Permittee Signature: 1 4. 4,I • AKii � Call (50 639 -4175 by 7:00 P.M. for an inspection needed the next business day Building Fixtures Plun'bin d Permit Application . . FOR OFFICE USE ONLY . �+ N Rece , � Plumbing 2 Date/By. �9 D Penrut No.: P (�oLYJ✓$ �d ED City ®f Tigard G�1� Date/By Planning Approval Sewer Permit No.: 13125 SW Hall Blvd. ►►►►vvvv Plan Review Other /'/ Tigard, Oregon 97223 9 Vin Date/By: Permit No n : 4- --CC C4 1 Phone: 503- 639 -4171 Fax: 503 \ 8 - '960 Post - Review Land Use Q �. 1/� ir g a 0 1 , Date/By Case No.: C- ur O J� ` ��DoZ Internet: www.ci.tigard.or.us o �iG _ I . • Contact Juris.: Z See Page 2 for 24 -hour Inspection Request: 50Q%9-1650\ 6SQ " ` - � - Name /Method: Supplemental Information. g a :a «�< ",`= <¢s" , » °,�� , " `' °`;�; - .� :�.� � xf'' " -�`r ..- .. - - - "'."""`_ -xs.� y,:'.� � r�....y -. ,. �,:°s : '�ss�,�zr- -- nitt a ,aMIST3 -0.0 Q ?K :; , .... ;.; , , ` '; ZM _ : tt C IO<Eve£or�sgecial s likililiK ❑ New construction ❑ Demolition Description I Qty. Fee(ea.) Total I Addition/alteration/replacement ❑ Other: '= °_ , = . ... k 4'' , , i, ewe. 2- 'fam�T'. >del "n s .; „` MOM _ = 'RY Q fi} 5, _. © _ , �' , } 4 '' - ..„1 a_�l`44 :4 :Nfo%°ea i�f�l t eoitnectiQ1$ .l: ` i :_;' M ,, �_CL.`0..- _...n_ >.:�'°_ . A7 SFR (1) bath 249.20 ❑ 1 & 2- Family dwelling ❑ Commercial /Industrial SFR (2) bath 350.00 Accessory Building ❑ Multi- Family SFR (3) bath 399.00 El Master Builder ❑ Other: Each additional bath/kitchen 45.00 l ;OB S 'I t C1 : :Rl IA T e* d x;O'CA O ll Fire sprinkler - sq. ft.: Page 2 Job site address: /o't"g5d ice. °:ry : 5_ t zi ' - r' S Itit1't`'res � : t x wT ., `� = . Suite #: /a2 g..5 Bldg. /Apt. #: Catch basin/area dram 16.60 Project Name: C , fj -�o - y ,, , h ' Drywell /leach line /trench drain 16.60 (J . Footing dram (no. linear ft) Page 2 Cross street/Directions t ob site: Manufactured home utilities 110.00 Manholes 16.60 Rain dram connector 16.60 Sanitary sewer (no. linear ft.) 15x1) Page 2 , 757•oo Subdivision: Lot #: Storm sewer (no. linear ft.) /00 Page 2 /p/ .y0 Water service (no. linear ft.) /00 Page 2 /D /• f Tax map /parcel #: _ ' J �: Fix nor ... ; I '` ; , = .' t 01);01 1IP IONTQ O'_.s bp Ct �. ,,'s.I :. Absorption valve 16.60 C : n / ,e�s4_,a l.�-1 Asa Backflow preventer Page 2 s �� o f , e ee- . Backwater valve 16.60 o Clothes washer 16.60 Dishwasher 16.60 Drinking fountain 16.60 Ejectors /sump 16.6 Name: -1 ft, - 7,9-144 -77/J f/UDC- "7 gyp 2& Expansion tank 16.60 Address: (% ® j P.'61' Fixture /sewer cap 16.60 City/State/Zip:-i5. c 40 ®P-- /OP Floor drain/floor sink/hub 16.60 Garbage disposal 16.60 Phone:? ' / 61s 00'6 Fax: 1O 7 Hose bib 16.60 III l4- re, G ,;, 6.60 I' .. ,`I')12SQ Ice maker 16.60 Name: L p Nv �Q- » &... ik - � � t- . Interceptor /grease trap 16 60 Address: } 1 D He`s c` -^ a.39-- '6''+ Medical gas - value: $ Page 2 City /State /Zip: N . 09_, 0i -1 ` �39 Primer 16.60 �° Roof dram (commercial) 16.60 Phone: -7cS - 4 4 g q Fax: ,9.9S -° /g9to Sink/basin/lavatory 16.60 E -mail: Tub /shower /shower pan 16.60 " z t k e :,' _ `° ON 0TO$ro r'i Y ' itc:4 ''11 Urinal 16.60 Business Name: � ';3 Co Water heater 16.60 Water heater r 16 60 Address: ( ii S«,) (hu t - itior..t. LI7) Other: City /State /Zip: ? (JVI at.. Gfl z .3 Other. ' Phone: x: z ' '' q _ .- .ate ,� . �x t: -1 " i q O t) Fax: 2 PI ; r bingl 'ermlt u : ds Subtotal $ CCB Lic. #: 5 237 - - Plumb. Lic. #: 31 -'1-0 Minimum Perrot Fee $72.50 $ �i� -2 84) Authorized Residential Backflow Minimum Fee $36.25 / d Signature: I i Date: " Z6--.1TJ Plan Review (25% of Pernut Fee) $ A6 T • 5 c b State Surcharge (8% of Permit Fee) $ 7 10. 3/ (Please print name) TOTAL PERMIT FEE $ /, ,Q 40 g . 5 ev 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. 1 \Dsts\Permit Forms\PlmPermitApp doc 01/03 Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: t gl < f ( �, �# ) °'� �•_...�.,. ,;,�,:.,;, r.:�,:*�.� �.�5 :. .,-r ' , , , _c _'� x k , ., *�,',.x,;;,`�.:� k : -Y. •'° � ". °* �g x ro�,, *;:;: il.; �@ p •,:A" ais„'< ;,, .: t otal} S llareFoota 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 y * ° :ti r ° " � . ya ':`y; * 5r: ":w�aluatiori :��rf ��`��y . p!; " ;�,`�:,z • �� � � . 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 additional $100 00 or fraction thereof, to and L ,._ �, , cture.or &"TEe iON, _ ° WQ r A elk= sl -�� �m•�� �� -��`_ �. 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 $37950 for the first $25,000 00 and $1 45 for Inspection of existing plumbing or each additional $100.00 or fraction thereof, to and including $50,000 00. specially requested inspections - per hour 72 50 Subtotal: $50 00 and up $742 00 for the first $50,000.00 and $1.20 for each additional $100 00 or fraction thereof. 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 *. ;;6',•. 7 3' • : 4.4074i/t b 4R ure)i vo k POfomte Comments regarding fixture work: Baphstry/Font Bath - Tub /Shower - Jacuzzi /Whirlpool Car Wash -Each Stall -Dnve Thru Cuspidor/Water Aspirator Dishwasher - Commercial - Domestic Deming Fountain Eye Wash Floor Drain/sink - 2" -3" - 4" Car Wash Drain *Note: If the fixture work under this permit results in an Garbage - Domestic Disposal - Commercial increase of sewer EDUs, a sewer permit will be issued and - Industnal fees assessed for the sewer increase must be paid before the Ice Mach /Refng. 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 Water Extractor Water Closet - Toilet Urinal Other Fixtures: is \Dsts\Permit Forms\P1mPermitAppPg2 doc 01/03 ~ Accumulative Sewer Tally Tenant Name: C E / i a eel atfrie� "-5 Scl,00 I. This SWR# Address: 12'x` S r"?..,./ ✓. — / This PLM #: 9 0 l ? — D D 3,0:1, Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New # Value Capped off value added # added #s total Count off #s count value values Baptistry/Font 4 Bath - Tub /Shower 4 - Jacuzzi/Whirlpool 4 Car Wash - Each Stall 6 , - Drive Through 16 , Cuspidor/Water Aspirator 1 Dishwasher - Commercial 4 Domestic 2 Drinking Fountain 1 0 ye Wash 1 Floor Drain /sink - 2 inch 2 1 . - 3 inch 5. - 4 inch 6 7 i f - Car Wash Drn 6 1 Garbage Disposal 16 ' - Domestic (to 3/4 HP) - Commercial (to 5 HP) 32 - Industrial (over 5 HP) 42 , Ice Machine /Refrigerator Drains 1 - . Oil Sep (Gas Station) 6 Rec. Vehicle Dump Station 16 Shower - Gang (Per Head) 1 , - Stall 2 !' Sink - Bar /Lavatory 2 & T - Bradley 5 - Commercial 3 - Service 3 - Swimming Pool Filter 1 Washer - Clothes 6 1 Water Extractor 6 - Water Closet - Toilet 6 3 3 - Urinal 6 / `7 - . TOTALS Total fixture values: divided by 16 = EDU HISTORY PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SW PLM# EDU# SWR# PLM# EDU# SWR# ildsts\swrtaly.doc /� OS6 s , -owec 6 Iv1e 01/4)01 Goy ��. I �` _ D ✓a3�r ' 0✓ rtiu„�4 r it/or /��� °. 0 , ' F r s Accumulative Sewer Tally _ _ Tenant Name:C FT ��A cleksA A-7.' Sc� Jo I 9 a This SWR# Address: 1 2 (75 sw 0vc�'r A v-e.. This PLM #: 2.0O3 — 3SR Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New # Value Capped off value added # added #s total Count off #s count value values Baptistry /Font , 4 Bath - Tub /Shower 4 - Jacuzzi/Whirlpool 4 Car Wash - Each Stall 6 - Drive Through 16 Cuspidor/Water Aspirator 1 /,� Dishwasher - Commercial 4 / ( „�` - Domestic 2 Drinking Fountain 1 ifil IY'Fl Pi--1,i. M-U ti-4,l (dal Eye Wash 1 Floor Drain /sink - 2 inch 2 • - 3 inch 5 . t{ . - 4 inch 6 I t - Car Wash Drn 6 Garbage Disposal 16 - Domestic (to 3/4 HP) - - - Commercial (to 5 HP) 3 , _ - Industrial (over 5 HP) 42 - Ice Machine /Refrigerator Drains 1 - Oil Sep (Gas Station) 6 Rec. Vehicle Dump Station 16 Shower - Gang (Per Head) 1 - Stall 2 �1 Sink - Bar /Lavato 2 i. t._ 1, t.- \._ ■ 1 l._ 1 111 / - Bradley 5 _ - Commercial 3 I CO ` - Service .3 - 11 v Swimming Pool Filter 1 Washer - Clothes 6 1 1 Water Extractor 6 Water Closet - Toilet 6 l isq t-14 I I rl I ' 1 ! ( — - Urinal 6 Iltl,rhtl 1 11 t GIP . TOTALS • Total fixture values: divided by 16 = EDU HISTORY PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# i:\dsts\swrtaly.doc BPia, gadv8a,•e1^ 41'39 -V1aa I CITY OF TIGARD 24 -Hour BUILDING Inspection Line: (503) 639 -4175 INSPECTION DIVISION Business Line: (503) 639 -4171 MST BUP Received &3 Date Res ested G PM BUP • Location � � � J` 6 s9%l Suite a v 3 Do ?,1 Contact Person - Ph ( ) 710 l - / S 7 PLM .;2Dd —06-2_35 l 6 - 2 _ 3 .5 Contractor Ph ( ) SWR BUILDING Tenant/Owner C F off ELC Footing Foundation ELC Access: Ftg Drain ELR Crawl Drain Slab Inspection Notes: SIT Post & Beam Shear Anchors Ext Sheath/Shear Int Sheath/Shear Framing Insulation Drywall Nailing Firewall Fire Sprinkler Fire Alarm Susp'd Ceiling / Roof Other: Final PASS PART FAIL PLUMBING 0 Post & Beam Rough -In Water Service Sanitary Sewer Rain Drains Catch Basin / Manhole Storm Drain Shower Pan /-) Other: 40 PART FAIL HANICAL Post & Beam Rough -In Gas Line Smoke Dampers Final PASS PART FAIL ELECTRICAL Service Rough -In UG /Slab Low Voltage Fire Alarm Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd. PASS PART FAIL SITE ° Please call for reinspection RE: Unable to inspect — no access Fire Supply Line ADA Approach /Sidewalk Date Inspector Ext Other: Final DO NOT REMOVE this inspection record from the job site. PASS PART FAIL CITY OF TIGARD 24 -Hour BUILDING Inspecticy'i Line: (503) 639 -4175 INSPECTION DIVISION Business Line: (503) 639 -4171 MST /01', g5 BUP Received Date Requested ‘ - 1 4-6- c -5��a PM BUP Location ., __ %.�.%� Suite M Contact Person Ph ( ) PLM --c CI ? Contractor Ph ( ) SWR BUILDING Tenant/Owner ELC Footing Foundation ELC Access: Ftg Drain ELR Crawl Drain Slab Inspection Notes: SIT Post & Beam Shear Anchors Ext Sheath /Shear Int Sheath /Shear Framing Insulation Drywall Nailing Fi rewal l _ mow_ i_ _ ��►3tir /, /! Fire Sprinkler Fire Alarm Susp'd Ceiling -Am di 1 Roof Other: Final PASS PART FAIL .LXJIVIBI Post & Beam nder SI • • Rough -In Water Service Sanitary Sewer Rain Drains Catch Basin / Manhole Storm Drain Shower Pan ether: 4 PART FAIL • HANICAL Post & Beam Rough -In Gas Line Smoke Dampers Final PASS PART FAIL ELECTRICAL Service Rough -In UG /Slab Low Voltage Fire Alarm Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd. PASS PART FAIL SITE 0 Please call for reinspection RE: El Unable to inspect — no access Fire Supply Line ADA /�2�� Approach /Sidewalk Date � �� � � Inspector Ext Other: Final DO NOT REMOVE this inspection record from the job site. PASS PART FAIL . .. . . _. .. . _ . . - • - - - _ ,...,----,--7.-„.;;;--4z,,iy:•.-,-,,,-zz-.-: , ..:- -,--.--,T.4-. . . _ . .. .. .... • -.. - - - . - _,... . .., . . ' . • , . , • . . , . . . . • . 1 . • ,-- - NEW „ k 1*.• BACKFLOW ASSEMBLY TEST REPORT EXISTING E5 REMOVED . PROPERTY ra REPLACED —OWNER: : . ' . . ,:, / .. c . - -- -. 67 i , E 41,,4,-, e 4 ONE: • , . .. MAILING — . ADDRES : %PI/ ••10/6yk‘• . . • - , . 1 483-. CITY STATE Orf■ Of STATE OP ZIP ASSEMBLY . " ADDRESS . ... . E R.P B.A. Fz, D.C.V.A E R.P.D.A. b.II.C.D.A. El P V.B.A. El S.V.B.A. MiA.V.B. MAIR GAP , ,_', 4 ;;L:- -.„ '',,,'--•„, .,-,;- . ':(.. ----- - ._ . V.': • ,. •;;. , ,, , 7,-. • .,-.... ::,i SIZE: 4 MAKE: : CO - -,. MODEL dP:5 - WATER - SERIAL . : . • - PURVEYOR a . 0 ,- - c i . NUMBER: . .-F -0.26K0 fi 7/0 ASSEMBLY ' • , • LOCATION: V C, /1 Alf Cos-1,01.--- I I i REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. ' INITIAL TEST #1 Check 00F4AECK . AIR CHECK PASSED X i Press. Drop INLET ...... _ . Check it 1 ‘ INITIAL ReliefValve Tight Irk lit Opened at: Press. Drop FAILED BE - • TEST Opened at: .-. . • . - - - . . RESULTS BUFFER min 2 psi Leaked is) psid - - .- Date: , , - . ... - - • . Check it 2 . • -- --- psid psis ' 2. 6 / - .. : "... ' -..' . . : : . -: - . . A - B = " mm 3 P Tight IV■Z 2 - SYSTEM RELIEF VALVE r L eaked —I— DID NOT FAILED PSI piz- . PASS , FAIL 71 , . B psid _ OPEN _ 7 I Comments .. 4 /C 7- , / and/or C . • ... Parts \-- -• . .• • , , . I I Reduced Pressure Assent -' P.V.B.A. / S.V.B.A. AFTER REPAIRS • Check # 1 , TEST Press. Drop pheck # 1 Opened at: Press. Drop Date: . • ., AFTER 'TI Ei — psid . , ' .- ' '.. , . -. • - • .. ' . REPAIRS Relief ght / / , ,, • Opened . .' mm 2 psi Check # 2 • • Buffer (Tight rm psid psid 2,s7d PASSED D A - B = min 1 ngi I • 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 regulations of the water system and glide regulations. UB "ATION DATE 47 2 - 6 i ."t -- GAUGE DA 1 -.. DETECTOR IftER-4?£ADINp - ------- ----- TESTER SIGNITUF4 ' ,,---- - — - — — • ..• TEsTER mAmE A i Gene Higgins - BAT C ER 11.1- IC ATION NUMBERS -- Oregon # 1129 • - - • . , .. . . . TEsTER AD.,4 1 15308 NE Bonanza Rd. . , . - - • Brush Praine. WA 9-8•6446-- Washingtow- ikos.23 , 12 TO 7 , cci3 # t5 COMPANY NAME ' A & A 'Inning, Clackamas, OR Phone. 503-284-3701 Gauge # 1189 , . - vcr‘vil,C rcmfORED REPORT RECEIVED BY . (REPRESENTATIVE OF OWNER) ef r YVHITE -WM SystonsCopy PINK -Customer Copy YELLOW -TostOr COOi, Page 1 of 1 • .:_._ . , . ...._. . • • • • • • -- -BACKFLOw ASSEMBLY TEST STING REPORT REMOVED PROPERTY r f/ REPLACED OWNER: PHONE: • • MAILING _ ADDRESS: ��t�Ji� I tr. siF' / • CITY , f • Q Y STATE Q ZIP ASSEMBLY'. ADDRESS' Spy iaq ® R.P.B.A. .C.V.A ® R.P.D.A. kk: C.D.A. a P V.B.A. C]S.V.B.A. Of A.V.B. n AIR GAP SIZE: MAKE: b • - MODEL I ( 'y WATER SERIAL // . .: -- PURVEYOR T% Y ' NUMBER: p� z � ? y _ •. � ASSEMBLY / - -. • .. LOCATION: ( s 4A - i - "" ii - := REDUCED PRESSURE ASSEMBL , • P.V.B.A. / S.V B.A. INITIAL TEST , i #1.Check -, bOUBLE:"CH EC ;• AIR CHECK I Press: Drop Check # 1 INLET PASSED INITIA ReliefValve Tight Opened at: Press. Drop FAILED TEST- - . Opened at: Date: RESULTS. BUFFER min 2 psi Leaked la$ psis _ ii i ? A - B mm 3 Check # 2 psid paid / /2 — �` Tight RELIEF VALVE DID NOT FAILED SYSTEM PASS n FAIL n Leaked ® paid . OPEN PSI Comments � Repairs ) (Pe /' • and/or � - 1 p 0 Parts 1— m) / / 4 / - , - • ( I Reduced Pressure Assembl 6.Ch .. A• • - P.V.B.A. / S.V.B.. AFTER REPAIRS Check# 1 #.F,, .. I TEST Press Drop Check # 1 AFTER ' Tight( J % Opened at: Press. Drop Date: REPAIRS Relief . ' psis Opened p Che c k # 2 t f! ' " a • psi mist 2 Buffer I B - B JT g ht _min paid paid paid PASSED - - - ' - " 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 regulations of the water system and state regulations. GAUGE CALIBRATION DATE 1./--/ a 63 _DETECTOR METER READING - TESTER SIGNITURE Gene Higgins - BAT CERIE NUMBERS TESTER NAME PRI /.� /� 15308 NE Bonanza Rd. Oregon # 1129 TESTER ADDRESS Brush Prairie. WA 98606 Washington # 0823 ' COMPANY NAME Back/low -- ,.9somblv'1'csting CCR # 127076 Phone 5'03- 780 -3823 Gauge `` #1189 REPORT RECEIVED BY (REPRESENTATIVE OF OWNER) yJ SERVICE RESTORED ' - • WrnE - w,ter System Copy FINN - c„uomerCoo Testers Page 1 of 1 YELLOW - epy ■ BACKFLOW ASSEMBLY TEST REPORT EX' NC F NEW -• REMOVED PROPERTY - y REPLACED OWNER: Gf oo P #d PHONE: MAILING ADDRESS: /` i Li a i CITY f t ( G gt d STATE 04 ZIP , ASSEMBLY f ADDRESS R +�t P - - i ® R.P.B.A. E D.C.V A ® R.P.D.A- .C.D. P.V B.A. BM S.V.B.A. A.V.B. EAR GAP SIZE: MAKE: tve 4/,-,,,, . MODEL ��� WATER -- J SERIAL PURVEYOR a r . f1 . • NUMBER: 5. /1/ £ 7 - ASSEMBLY LOCATION: r oY� .o� i frrA- . L AI • " 44 I REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST " -1 Check • _ OO,UttEi<, EEC • 'AMR • " CHECK PASSED X . Press. Drop Ch k # 1 ' - - ' INLET TEST L Openedaat Tight Opened at: Press. Drop FAILED g • f RESULTS BUFFER mm 2psi Leaked Bi. paid Date: 12-74-7 g = Check # 2 ; . , - paid paid 70/ n n 3 psi Tight r - SYSTEM RELIEF VALVE Leaked pkld - DID NOT FAILED PSI el' PASS n FAIL n OPEN n n Comments 3 l/ j Repairs (( "� f �� _. - - and/or Parts . • - . Reduced Pressure AssembIVDa e,;ci P.V.B.A. / S.V.B.A. AFTER REPAIRS Check # 1" Check # 1 TEST Press. Drop L. ht I I Opened at: Press. Drop Date: d Relief t R PA RS Opened 9 ® / / t ' min. 2 psi 'Check # 2. - - Buffer _ B = 'Tight 4 p aid psia paid PASSED ft min 9 nct ■ 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 . ." regulations of the water system and to regulations. GAUGE CALI:RAT •N DATE .- • 11 .1 DETECTOR METER READING t TESTER SIGNITUR _ -' - - Higgins - - CERT Y TESTER NAME PRI• *. Gene - BAT CERTIFICATION NUMBERS �- Brush Prairie, WA 98606 Oregon - # 1129 TESTERADDRe : A & A Dnlling, Clackamas, OR Washington # 0823 Phana. .5D3- 8d -37Q1 CCB # 127076 COMPANY Gauge ri! f f 69 lll��� )RED REPORT RECEVED BY . (REPRESENTATIVE (A- I WNEN) ' " • • • WHITE - Water System Copy PNK - Custmpr Copy YELLOW - Tester Copy - Page 1 of 1 - • - . I