Permit CITY TIGARD PLUMBING PERMIT
40 41 , i DEVELOPMENT SERVICES PERMIT #: PLM2001 -00368
4,1
-- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 63 -4171 DATE ISSUED: 08/15/2001
SITE ADDRESS: 10859 SW KABLE ST PARCEL: 2S110DA -09500
SUBDIVISION: ERICKSON HEIGHTS ZONING: R -3.5
BLOCK: LOT: 056 JURISDICTION: TIG
CLASS OF WORK: ALT 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: Irrigation backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
PRMT CTR 08/15/2001 $36.25 27200100000
5PCT CTR 08/15/2001 $2.90 27200100000
Total $39.15
Phone 1:
Contractor:
MOODY ENTERPRISES INC
PO BOX 713
ESTACADA, OR 97023 REQUIRED INSPECTIONS
Phone 1: 503 - 630 -5532 Final Inspection
Reg #: LIC 5973
PLM 11717
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: Permittee Signature: ci)--2 9�
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
- - itisr2o a -2/
, • _ Plumbing Permit Application Lfi
Date received: "/2/0 / Permit no. / 0l 403b f
H' " y°4111j City of C Tigard F
Al 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: By429. Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
4 1 & 2 family dwelling or accessory 0 Commercial /industrial 0 Multi - family 0 Tenant improvement
New construction 0 Addition/alteration /replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: Mg r47 5 k/ /abl C 5- Description Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: New 1- and 2- family dwellings only;
(includes 100 ft. for each utility connection)
Tax map /tax lot/account no.: SFR (1) bath
Lot: j IBlock: `Subdivision: SFR (2) bath .
Project name: 54 ;k5 H a lif SFR (3) bath
City /county: 7/1 q h a I ZIP: 9 7 22? Each additional bath/kitchen
Description and location of work on premises: rpL% _ Site utilities:
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:. 0 it C iy• T.,".4./ X4 /74 „ •,.,. ti`- • Manholes
Address: PC), C 7/3 Rain drain connector
City: FS faCeicie/ I State:OP, I ZIP: Cf 70 2.3 Sanitary sewer (no. lin. ft.)
Phone: d, - 630. -5 s j' 2. I Fax:5 -'c I E -mail: Storm sewer (no. lin. ft.)
CCB no.: /17/7 Plumb. bus. reg. no: Water service (no. lin. ft.)
J I g �y 7 '� Fixture or item: •
City /metro lic. no.:
Absorption valve
Contractor's representative signature: 1 1)< /b/ /� /�i✓ Back flow preventer
Print name: / : Al Date: //
p ` � � 7 � � / Backwater valve
CONTACT PERSON Basins/lavatory
Name: , / 7 / ., .fi , 0 ,, Clothes washer
Address: J , f Dishwasher
City: Z 5 yead I StatetC/ I ZIP: 17 °2Y Drinking fountain(s)
Ejectors /sump
Phone:., f "o ? - C34 , Fax: f' -. jit E -mail: Expansion tank
OWNER - Fixture /sewer cap
Name (print): 0 iqtN4G 140111 14 Floor drains/floor sinks/hub
g ( 2 � (LA fi mg gr,;..
Garbage disposal
Mailin address:6b -- `` Hose bibb
City: W T U N N I State: I ZIP: 110 Ice maker
Phone S4 a 0190 ®I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me o e p : •ntenance and repair made by my regular Roof drain (commercial)
employee on the pr', , I ,wn as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: �� i Date: 4 7 . 1 el Sump
ENGINEER :Tubs/shower /shower pan
Name: Urinal
Water closet
Address: Water heater
City: I State: ZIP: Other:
Phone: Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ .SC , ZS
Notice: This permit application
l] visa 0 MasterCard expires if a permit is not obtained Plan review (at %) $
Credit card number: • - " ir within 180 days after it has been State surcharge (8%) .... $ . 90
Ex
p TOTAL $ 39. 1.6
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount
440-4616 (6/00iCOM)
1/9/2002 Activities for Case #: PLM2001 -00368
8:33:24 AM
Assigned Hold Updated
Activity Description Date 1 Date 2 Date 3 To Done By Disp. Level By Updated Notes
PLMA003 Application received 8/2/2001 BB RECD No Hold DLH 8/8/2001
PLMA005 Create Permit 8/8/2001 DLH DONE No Hold DLH 8/8/2001 ,
PLMA799 Final Inspection 12/11/2001 TLP PASS No Hold TLP 12/11/2001
PLMA040 (F) Ready to issue 8/8/2001 DLH DONE No Hold DLH 8/8/2001
PLMA050 (F) Issue permit 8/15/2001 BB DONE No Hold BB 8/15/2001
PLMA800 Case Finaled 12/11/2001 TLP PASS No Hold TLP 12/11/2001
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