Permit "" CITY OF TIGARD
PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT #: PLM2000 -00009
'�'i 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED:
SITE ADDRESS: 10530 SW JOHNSON ST PARCEL: 2S103AA 01915
SUBDIVISION: COTTONWOOD PLACE ZONING: R -4.5
BLOCK: LOT: 014 JURISDICTION: TIG
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: 1
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: • . WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Plumbing reversal from septic tank to sanitary sewer.
FEES
Owner:
Type By Date Amount Receipt
LAMBERT, ROBERT A PRMT BON 01/10/200C $50.00 00- 321035
10530 SW JOHNSON ST 5PCT BON 01/10/200C $4.00 00- 321035
TIGARD, OR 97223
Total $54.00
Phone 1:
Contractor:
LARRY CAM ERON PLUMBING
1812 SE 158TH AVE .
PORTLAND, OR 97233 REQUIRED INSPECTIONS
Phone 1: 503 - 256 -2705 Sewer Inspection
PLM /Underfloor •
Reg #: LIC 49792 Final Inspection
PLM 26 -366PB
ORIGINAL
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 - 0001 -0080.
You may obtain copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued By:,(, ,a4dif/c— Permittee Signatur:. �j i , , ' de
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next b; si 'ss day
CITY OF TIGARD Plumbing Permit Application Plan Check#
131 f-SW BLVD. Commercial and Residential Rec'd By_
TIGARD, OR 97223 Date Recd i - lb - 00
(503) 6.39-4171 • Date to P.E.
Print or Type Date to DST
Incomplete or illegible applications will not be accepted Permit# FLt41 uX� v�
. Related SWR #
Called
Name of id
'FI
o
Development/Prject XTR
UES (indivual); >' °nQTY ', PRICE ; AMT"
rr _--- � .,,,..,,_m, ��.< - ., .,... ,�',�• : all ',To �., ,,�,�,.,�� ".
Job wd_ 66 !(�. ff(AA- Sir::. 11.50
Address Street Address Suite Lavatory • 11.50
Tub or Tub /Shower Comb. 11.50
Bldg # City /State Zip Shower Only 11.50
Name Water Closet 11.50
. 040 Z44frt Urinal • 11.50
Owner Mailing Address Ste Dishwasher 11.50
)05 �L 1 5O I �dl s Al J Garbage Disposal 11.50
City /State Zip Phone
e 77 1 K .0 6 X Laundry Tray 11.50
Name Washing Machine /Laundry Tray 11.50
.5A64&7- Floor Drain /Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" - 11.50
4" 11.50
City /State Zip Phone
• Water Heater 0 conversion 0 like kind 11.50
Name /1 C' Gas piping requires a separate mechanical permit.
e-41/4-1/A) /2 P7Y � �� ,/ { / MFG Home New Water Service . 32.00
Contractor Mailing Address t'r / � Suite MFG Home New San /Storm Sewer 32.00
/1/2- x i /sa /)/ 4 '' - Hose Bibs 11.50
Prior to permit C /State
/ Phone Roof Drains 11.50
issuance, a copy X� 33 Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if 2° Other Fixtures (Specify) 15.00
expired in COT Plumbing Lic ` Exp. Date
database - :3t / . (p to Re t4u ruAlkoko r
Name J
•
Architect Sewer - 1st 100' 38.00
or Mailing Address Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00
Engineer City /State Zip Phone
Water Service - each additional 200' 32.00
Describe work to be done: Storm & Rain Drain - 1st 100' 38.00
New 0 Repair 0 Replace with like kind: Yes No 0 Storm & Rain Drain - each additional 100' 32.00
Residential 0 Commercial 0 '
Additional description of work: Commercial Back Flow Prevention Device 32.00
. Residential Backflow Prevention Device* 19.00
80 gj fee 00 4 Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes 0 No 0 Inspections per /hr
If yes, see back of form to indicate work performed by r Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES. .a ::.;_,,
I hereby acknowledge that I have read this application, that the information
QUANTITY TOTAL i . ; .; ; , F; .,,
given is correct, that I am the owner or authorized agent of the owner, and Isometric or riser diagram is required if Quantity Total is > 9 4y:;.`- �: s < 'it
*SUBTOTAL ' % ;. v; , ,,F•,5 >, .r
that plan submitted are in compliance with Oregon State Laws. > _;. A
Si, •tas of Owner / ..•ji Date y %: , :.: %hy > °
// a //! f - /d -- 00 8% SURCHARGE �,,: 7,1,4±,---, '; , j Oft/ Contact Pers • /.ame Phone a a ` `�
Z7d �' * * PLA N REVI 25% OF SUBTOTAL 3 ; ,: r f , ;° -
�n� ss� >v ash ;,
1B THI- HOUSEg 1 8:0 " Required only if fixture qty. total is > 9
. `: TOTAL -,
� Z B TH�OUSE,o 40 z s . - -
=, < g 9 1 `Miimum permit fee is $50 + 8% surcharge, except Backflow Prevention
t Residential B
,, {Th�s=�fee rcludesat Irtum, fiztu� in,�e� the fi rst Q, n p Q s p
>F'I,OQ ±of 5 i sewe storrr►;setaer an; �atar�rvice ;� tK .�Y ''mss Device, which is $25 + 8 /o surcharge
... .._ ) _
"All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i:\dsts \formstplumapp.doc 11/18/99 - -
•
PLEASE COMPLETE: _- - - -_ - - -_ -� - -- _- - -- - -- -
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t r e �. Quanfii br WorkPe' orrne; ° �
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Sink
Lavatory •
. Tub or Tub /Shower Combination
Shower Only
Water Closet
Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3 "
4"
Water Heater
Other Fixtures (Specify) .
•
COMMENTS REGARDING ABOVE:
I: \dsts for ms\plumapp.doc 11/18/99 - -