Permit CITY OF TIGARD
PLUMBING PERMIT
4 DEVELOPMENT SERVICES PERMIT #: PLM2001 -00333
„� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/6/01
SITE ADDRESS: 08817 SW GREENING LN PARCEL: 2S111DA -18000
SUBDIVISION: APPLEWOOD PARK NO. 3 ZONING: R -7
BLOCK: LOT: 173 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
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: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of residential backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
LEGEND HOMES PRMT CTR 8/6/01 $36.25 27200100000
12755 SW 69TH AVENUE #100 SPOT CTR 8/6/01 $2.90 27200100000
PORTLAND, OR 97224
Total $39.15
Phone 1: 503 - 620 -8080
Contractor:
AUTUMN LEAF LANDSCAPING LLC
1209 INDEPENDENCE CT.
WOODBURN, OR 97071 REQUIRED INSPECTIONS
Phone 1: 503 - 982 -1415 RP /Backflow Preventer
Reg #: PLM 7265 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 Utility
Notific. '= - - -nter. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
Yo , may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Is . ued By :' /1 .. "0/ • ' , it / I Permittee Signature:,
Call (5031-61-4175 by 7:00 P.M. for an inspection needed the next business day
. - -•
Plumbing Permit Application
Date received: i 0/ Permit no.: 4./ 2 /,4) a j3
hiyA -> 1 \ City of Tigard
�! Sewer permit no.: Building permit no.:
Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 - 4171 Project/appl. no.: 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 D Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: / 7 � yee , yz ,(� Description Qty. Fee(ea.) Total
Bldg. no.:Suite New 1- and 2 -family dwellings only:
Tax map /tax lot/account no.: (includes 100 ft. for each utility connection)
SFR (1) bath
Lot: I Block: Subdivision: SFR (2) bath .
Project name: SFR (3) bath •
City /county: 72 ✓r/ ZIP: Each additional bath/kitchen
Description and lotation of work on premises: ✓ a . "A. AU. \ Siteutilities:
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: - A' r " c - Manholes
Address: 10 X 6 Rain drain connector
City: k I StateC9A I ZIP:97( j `7 Sanitary sewer (no. lin. ft.)
Phone: '71 e0 - -Cy r f Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: 7-=z & 4 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 y •
Print name: / r k ;/ Date: a Backwater valve
CONTACT PERSON Basins/lavatory
Name: Clothes washer
Address: Dishwasher •
Drinking fountain(s)
City: State: . I ZIP: Ejectors/sump
Phone: Fax: E- mail: Expansion tank .
OWNER Fixture /sewer cap
Name (print): Floor drains/floor sinks/hub
Mailing address: Garbage disposal
Hose bibb
City: I State: I ZIP: Ice maker
Phone: I Fax: I E -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: Date: Sump
ENGINEER Tubs/shower /shower pan
Name: Urinal .
Water closet
Address: Water heater -
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ L J a
Notice: This permit application
❑ Visa ❑ MasterCard expires if a permit is not obtained Plan review (at %) $
Credit card number: / / within 180 days State surcharge (8 %) .... $ ,V.. 90
Expires ays after it has been TOTAL $ 3? . l
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount ■ 440.4616 (6/00 /COM)
PLUMBING PERMIT FEES:
, il!FPC,E4i
FIXTURES (individual) QTY (ea) !'f(101,Ude0'.!#44.irribiFgItYitke:01',in f RIE TOTAL
Sink 16.60 the OIL; QTY (ea) :1*01.1N.V:
foi:eadh
Lavatory 16.60
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 :,',Qtlaritity by Work "Prfitirthe4 -
Gas piping requires a separate mechanical Fixtige.Type: Repla*,,S Removed/
• .• 4
permit.
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"
Sower- 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 plans with isometric or riser diagram and
plan review.
iAdsts \forms \plm-fees.doc 10/10/00 •