Permit ' a CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT PERMIT #: PLM2008 -00444
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 12/2/2008
PARCEL: 2S102DC -05200
SITE ADDRESS: 13794 SW HALCYON TER ZONING: R -4.5
SUBDIVISION: GERTZ HOMES AT EDGEWOOD LOT: 002 JURISDICTION: TIG
PROJECT: GERTZ HOMES AT EDGEWOOD
Project Description: Install backflow of irrigation system.
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
Owner:
FEES
GERTZ CONSTRUCTION COMPANY, INC.
19200 SW 46TH AVE Description Date Amount
TUALATIN, OR 97062 [PLUMB] Permit Fee 12/2/2008 $36.25
[TAX] 12% State Surch 12/2/2008 $4.35
Phone : 503- 692 -3390 Total $40.60
Contractor:
TERRA -SOL LANDSCAPING
21685 SW HEDGES DR
TUALATIN, OR 97062 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 691 -6105
Reg #: LIC 5019
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of •,R-- Speei. ty Codes and all other
applicable laws. All work will be done in accordance with approved plans. This permit will expife if work is not started within 180 days of
issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law re9uir -s .\ • follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through O R 952-0001-0100. ou may obtain copies of
these r - •r .i - suestions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issu By: _ ���L / (, Permittee Signature (
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 com • et. • of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
ABuilding Fixtures FOR OFFICE USE ONLY
City of Tigard Received ,,, n /).
4/1 jA io 06 O .
/ 1/4....._, )) Permit No.: (.., , i „
q 13125 SW Hall Blvd., Tigard, OR 97223 Date/By:
Plan Review
: 111 1 - I . Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No.:
Inspection Line: 503.639.4175
TIGARD Date Ready/By
Internet: www.tigard-or.gov Notified/Method • Supplemental 2 for
Supplemental Information
:''''- i:Irk:!ciY WORK '',. ',-:,. ', ::, 2 : , :s'';' , :!?: - - 7- ;'''''.:' 1 .' - ' ,' ':'•.: ': ,'''' - , \_ ' : , 't',,kE
--' - - - ' - - -
New construction Demolition
For special information use checklist.
LI
Description Qty. Ea. I Total
ID Addition/alteration/replacement 0 Other: New 1 - 2 dwellings (includes 100 ft. for each utility connection)
.„' ' CATE_GORY„ OF CCiNS'ift1J,Ct1ok ,:q :f:::-';...' i SFR (1) bath 249.20
1 and 2-family dwelling ID Commercial/industrial SFR (2) bath 350.00
Eil Accessory building 0 Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
El Master builder E Other:
Fire sprinkler ( sq. ft.) Page 2
••,.,'•:: ',',:t:',,„ ••;.:. '.'::. &,c:J04 : SITELINFORMATIO AND' ocgloN - ,1,': :. ,. z , ,, , , , , ,,,, - ` ,, ' , okP::::!' Site utilities
Job site address: 1 . 57i . L i i 61.A.J Ak.C-10 /Li -71,
Catch basin or area drain 16.60
City/State/ZIP: Drywell, leach line, or trench drain 16.60
Suite/bldg./apt. no.: Project name:
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.: ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Subdivision: Lot no.:
Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map/parcel no.:
0.bsorption valve..
,,,.:,'_..,,' i , ,;,..:-;• - , _ ,,, ',_,= -.-, -:. - ,1)ESCRIP, , TION,OFfyVOW: ' :,! `0: ., -', .' , - ' '. Etackflow reventer ._„..)-
t Page 2
-_.._ ..._____ _ --
r ?A<: \ t- Fcew -. 3Q.52,1/4, U, /4CtuaTik.) Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
: i'% .V,N ,• • •- .-, Drinking fountain 16.60
1[ ii' ' '''. '.':' ' l;'.; : - M ,TEN'A '
NT1 r ;!.' ,,,
- 06 1,1 '-' - ' " ' - ' - - " - ' ' ' Ejectors/sump 16.60
G
Name: cy,\--2 v
e-,t Expansion tank 16.60
Address: Fixture/sewer cap 16.60
City/State/ZIP: Floor drain/floor sink/hub 16.60
Phon6(0 ) (P. k i 2 . - 312 Fax: ( ) Garbage disposal 16.60
• , ".' a.A.PPLICANT - ;,, - , 0 CONTACT, PERSON :. 16.60 ':..', -
Ice maker 16.60
Business name:
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: ( ) Fax: : ( )
Tub/shower/shower pan 16.60
E-mail:
. Urinal 16.60
t.;.; '--7 :::',;:: Water closet 16.60
, „ _
,--,„
Business name: 7 ( i 14 • , ..) I
Water heater 16.60
Address: 61A i i(0 02, 5 ..&,ti :ac lz, Other:
Subtotal
City/State/ZIP: ---- ,.. ,4 . ' 470V
Minimum permit fee: $72.50 & ? 5
71 , C
Phone6t3 '... 1 , I - .. ,t Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: - L9 T Plumbing Lic. no.: Plan review (25% of permit fee) --O
State surcharge (12% of permit fee) q .s ...-
i
TOTAL PERMIT FEE 10 6,0
' Print nami4 1 y . i • ■• rn, if , #1.- Date: I 2- / 2 -/Dr 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.doc 12/27/06 440-461 6T(1 0102/COM/WEB)
Plumbing Permit Application - City of Tigard"'
•
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site.Util tees , Qty Fee (ea) Tota Square Footage Permit Fee„ 1
Footing drain - ls` 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: w V w. ` I Fee:' ;,•' . F }tea
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
'Qty: ' , Ta additional $100.00 or fraction thereof, to and
;;Figture Iteiri; .:' , . Fee. T otal r
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
Inspection of existing plumbing or each additional $100.00 or fraction thereof, to
specially requested inspections - per hour 72.50 and including $50,000.00.
Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for
each additional $100.00 or fraction thereof.
Commercial Fixture Work: ,,;Plan Review'_for Plumbing,Ins`tallations; : 4, •
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
' Quaiiti by (Fixture) Work'P,erformed greater, except systems designed and stamped by licensed
^....,b '.; engineer.
Fixture Type:,.. . Replace
Added' 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 ;va Isometric or Riser Diagra m'`, ,
Drinking Fountain
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
TIM A. AUFENTHIE dba T &R Building Services 6949
w `660 �iogue Lane, Wilsonville, OR 97070
4
(503) 318 -6313 FAX (503) 682 -4466 ,
� � ,::,
CCB# 116054 El E sTI
P NWS -AWWA BAAKFLOW ASSEMBLY TEST REPORT ❑ R �'
PROPERTY TP A ' ( 0 1 L t C .Q ❑ REPLA MENT
OWNER: PHONE:
r
MAILING
ADDRESS:
CITY STATE ZIP
' S DD RES SY 1 3 -791/ 'S 1 ' / J A G yO/j l!` ee`
STREET
❑ R.P.B.A. ❑D..C.V.A. ❑ R.P.D.A. ❑ D.C.D.A� O P.V.B.A. ❑ S.V.B.A. ❑ A.V.B. ❑ AIR GAP
SIZE: I I i I -1� ( I CP MAKE: kAJ 1 1.0 IBS MODEL: U
WATER "1- ^
PURVEYOR: ' �: J r �` 0 l NUMBER: `G
ASSEMBLY I .c 1' 4 t
c ✓ cAA - 400--
LOCATION: (` 1
REDUCED PRESSURE ASSEMBLY P.V.B.A. / S.V.B.A. INITIAL TEST
#1 CHECK 1 "-` _�% AIR CHECK - PASSED A PRESS DROP ( At . ._ CHECK #1 INLET FAILED ❑
RELIEF VALVE
INITIAL OPENED AT (B) TIGHT igt I • 46 OPENED AT: PRESS DROP
MIN 2 PSID PSID DATE;
TEST LEAKED ❑
RESULTS BUIl B = MIN 3 PSI P SID PSID 1 II `
A - B = CHECK � Z
TIG D DID NOT FAILED SYSTEM VALVE R PAS F ❑ FAIL ❑ LEAKED ❑ PsID OPEN ❑ ❑ PSI
COMMENTS
REPAIRS
AND/OR
PARIS
j.
REDUCED PRESSURE ASSEMBLY ' AFTER REPAIRS
#1 CHECK ^ . " ACVA . P.V.B. A. / S.V.B.A. DATE:
TEST PRESS DROP (A) , CHECK #1
RELIEF t OPENED AT PRESS DROP
AFTER OPENED mw 2 FILD (B) TIGHT ❑ PSID
I
REPAIRS n B R , CHECK #2 PASSED ❑
MIN 3 PSI , TIGHT ❑ PSID nil) PSID
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 / I2 ( I �+ DE`fCTOR METER READING
�r 3466 "
TESTER SIGNATURE TIM A. AUFENTHIE. - CERT#
20061 a
TESTERS NAME PRINTED GAUGE # i
8660 Rogue Lane, Wilsonville, OR 97070 (503) 318 -6313
TESTERS ADDRESS T & R Building. Services _ PHONE
COMPANY NAME
1 , X SERVICE RESTORED
REPORT RECEIVED BY (REPRESENTATIVE OF OWNER)
WHITE - Water System Copy PINK - Customer Copy YELLOW - Tester copy
CITY OF TIGARD , ,; „,.. • .
BUILDING DIVISION
et PERMIT #: PLM2008-00M4
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 1212/2008
Phone: (503) 639-4171
Inspection Requests (24 Hrs.): (503) 639-4175 44 AJJ.
INSPECTION WORKSHEET FOR DATE: 12/9/2008 TIME: 7:02AM PAGE: 20
• SITE ADDRESS: 13794 SW HALCYON TER CLASS OF WORK:
SUBDIVISION: GERTZ HOMES AT EDGEWOOD LOT #: 002 TYPE OF USE:
PROJECT NAME: GERTZ HOMES AT EDGEWOOD
DESCRIPTION: Install bacIdlow of irrigation system.
liC.0■0
OWNER: GERTZ CONSTRUCTION COMPANY, INC., • PHONE #: 603-692-3390
CONTRACTOR: TERRA-SOL LANDSCAPING PHONE #: 503.691-6A
Inspection Request Scheduled For: Date: 12/9/2008 Pour Time: fipli:
Code # Inspection Description Confirm # Contact # Mes
396 Mk% inspection_ 07888B-01 5'03-691-6105 . tjt "
( PU-A. .
Corrections /Comments/ Instructions:
4-- R—.eA A--4C--z--z:i
O. 6 q 1 0
ri ;14 A A-0
3) 3i
N .......
7 .ASS 0 PARTIAL APPROVAL D CANCEL E NO ACCESS
FAIL 7 CALL FOR INSPECTION 0 ADDITIONAL FEES A SSESSED
O __________,
1)
Inspector: Date: Phone #: (503) 718-
„ . .