Permit i
C ITY OF TIGARD PLUMBING PERMIT
1111 : COMMUNITY DEVELOPMENT PERMIT #: PLM2008 -00418
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 10/28/2008
PARCEL: 2S 112CB -09200
SITE ADDRESS: 15196 SW KENTON DR ZONING: R -7
SUBDIVISION: ASHFORD OAKS NO. 2 LOT: 106 JURISDICTION: TIG
PROJECT: WORNATH
Project Description: Bathroom remodel.
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:
TUB /SHOWERS: 1 SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
HARRY WORNATH
15196 SW KENTON Description Date Amount
TIGARD, OR 97224 [PLUMB] Permit Fee 10/28/200E $72.50
[TAX] 12% State Surch 10/28/200E $8.70
Phone : 503- 472 -1657 Total $81.20
Contractor:
HOLLINGSWORTH PLUMBING
13624 DUANE ST
OREGON CITY, OR 97045 -2869 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 655 -5533
FAX same
Reg #: LIC 65325
PLM 26 -324PB
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 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
_
Issued B
/....-
/ �. �� _ Permittee i nature: �� J ,�(/�
Call 503.639.4175 by 7:00 a.m. for an inspection that busines day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
" Plumbing Permit Applicat ®n ��®,` 'la
Site Utilities ® ®� FOR OFFICE USE ONLY
City of Tigard � ® ® � ® �g `' %•ate / B d / /�/ / / UV PermitNo.: �� �jj� /le
111
- v 13125 SW Hall Blvd., Tigard, OR 97223 %_ l y " - /
Plan Re
Phone: 503.639.4171 Fax: 503.598.1960 1 % I, ; e v, Other Permit No.:
T I G A R D Inspection Line: 503 4175 t }1 a , , , ' I x. ' +: y : luris See Page 2 for
Internet: www.tigard- or.gov ethod: a(t) Supplementallnformation
FEE* SCHEDULE'"-
❑ New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
, , , k , ":", - - $,° , °'„,., ,, ,r - : =CATEGORY OF CONSTRUCTION, , , .', : ° _ h SFR (I) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
� s Fire sprinkler ( sq. ft.) Page 2
! • JOBe SITE INFORMATI N i LOCATION''`° y -,a,
,, , , _. . _ , _ ... Site utilities
Job site address: 151 S 5 W V yc - 1p, ' - V Catch basin or area drain 16.60
City /State /ZIP: T`C, A 2 ' ti 2:2_,}i- Drywell, leach line, or trench drain 16.60
Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: ` I Project name: j� ) Cnvc(
Vv 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
Absorption valve 16.60
' DE' O_ .'"
� t.,. > DESCRIPTION WORK
-. ... � Backflow preventer Page 2
' L1 rt,. Yom Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
-. - -• Drinking fountain 16.60
'., .,-,,- ' • I I °',PROPERTiii O OWNER °. _ "x : µ l , 0' T ' • ' ,
�`''' Ejectors /sump 16.60
Name: 4-4a,Y,r. u )64 0-Ci + %\ Expansion tank 16.60
Address: ? 6 . r- 1 d l J Fixture /sewer cap 16.60
City /State /ZIP: YY\,11 n Li AL, 6 R . Si. (ZF" Floor drain /floor sink/hub 16.60
Phone: (g.>3) 41 ).., - ‘, � 61 Fax: ( ) Garbage disposal 16.60
t APPLICANT» ❑r CONTACT ": PERSON' Hose bib 16.60
_.r., �... n . 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 b. G (,
E -mail: Urinal 16.60 /
a. •.°CONTRACTOR
i � ' �7 Water closet 16.60
Business name: .HtU k t ockT4�a l "\V vk- blvx --� Water heater 16.60
L2 s
Address: 1 b - ' t cJk , Other.
/State /ZIP: 6 ` t Subtotal
City/State/ZIP: �� ��T 1U�S Minimum permit fee: $72.50
Phone: ( .03) 3 lci i -LA Fax: ( ) Residential backflow minimum permit fee: $36.25 .
CCB Lic.: ( 3 1.5- Plumbing Lic. no.: 26- 32(-P5 Plan review (25% of permit fee)
State surcharge permit fee) ' / 70-
Authorized signature: )44.. - TOTAL PERMIT FEE 8/
Print name: ; re L. �p �� Date: - �,0 7 )_ g f zeroi3 This permit application expires if a permit is not obtained within
I 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
l \Building\Permrt$\PLMU- PermitApp.doc 12/27/06 440- 4616T(10/02 /COM/WEB) .
Plumbing Permit Application - City of Tigard .`
Page 2 - Supplemental Information •
Fee Schedule: Residential Fire Suppression Systems:
'Site Utilities Q : Fee (1 T0,011' ` ,
S Fo '.Permit Fee
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 3. -
}Valu " atop: �� , e ` I ; :. "' - Permit ; Fee. � " °;.:� °�� �� �.•�,.;
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
Fi%t11rC.Or Iten1�, a * ",' QtyC, 'Fee(ea)` ° Totah additional $100.00 or fraction thereof, to and
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
and including $50,000.00.
specially requested inspections - per hour 72.50
Subtotal: $50,001.00 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 °R "eview. for Plumbing Installations; , -'
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
Quantity' b'y (Fixture)Mork Pe'rfo'rmed, .': greater, except systems designed and stamped by licensed
• engineer.
Ftxtnre Type .` � ' ' ' ` .Replace
, . �
'Previous = "Capped Added' ;" Existing. ❑ 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
Drinking Fountain
aI sometrie ' o r ser' Diagrain _
Eye Wash ❑ Isometric or riser diagram is required for new buildings
Floor Drain /sink - 2" that meet the qualifications above.
-3"
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 \PLMU - PermitApp.doc 2
CITY OF TIGARD
COMMUNITY DEVELOPMENT
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171
Plumbing Signature Form
IMPORTANT PERMIT NOTICE
HOLLINGSWORTH PLUMBING
13624 DUANE ST l
*
OREGON CITY, OR 97045 -2869'
(0 00
e
CPO
Permit #: PLM2008 -00418
Date Issued:
Parcel: 2S112CB -09200
Site Address: 15196 SW KENTON DR
Subdivision: ASHFORD OAKS NO. 2
Lot: 106
Jurisdiction: R -7
Zoning: TIG
Project Name: WORNATH
Description: Bathroom remodel.
Your company has been indicated as the plumbing contractor for the permit referenced above. In order for the
plumbing permit to be valid, please have the appropriate individual from your company sign below and return this
Plumbing Signature Form prior to the start of the work. Please mail the form to: City of Tigard, Building Division,
13125 SW Hall Blvd., Tigard, OR 97223, or you may fax the form to: 503.624.3681.
If you have any questions please call 503.718.2433.
No plumbing inspections will be authorized until this completed form is received
OWNER: PLUMBING CONTRACTOR:
HARRY WORNATH HOLLINGSWORTH PLUMBING
15196 SW KENTON 13624 DUANE ST
TIGARD, OR 97224 OREGON CITY, OR 97045 -2869
Phone #: 503 - 472 -1657 Phone #: 503 - 655 -5533
Reg #: LIC 65325
PLM 26 -324PB
AN INK SIGNATURE IS REQUIRED ON THIS FORM
' -1 •W: Arc iledA kliSt
. �
Signature of Authorize• Plumber Name (printed)
CITY OF TIGARD • BUILDING DIVISION PERMIT #: PLM2008-00418
13125 SW Hall Blvd., Tigard, OR 97223 ..f DATE ISSUED: 10/28/2008
Phone: (503) 639 -4171 �iovd�ulMyig6lli�Irl
' '
Inspection Requests (24 Hrs.): (503) 639 -4175 SE..
INSPECTION WORKSHEET FOR DATE: 11/130008 TIME: 7:00AM PAGE: 31
SITE ADDRESS: 15196 SW KENTON DR CLASS OF WORK:
SUBDIVISION: ASHFORD OAKS NO. 2 LOT #: 100 TYPE OF USE:
PROJECT NAME: WORNATH
DESCRIPTION: Bathroom remodel
OWNER: WORNATH, HARRY PHONE #: 603 -472 -1557
CONTRACTOR: HOLt INGSWORTH PLUMBING PHONE #: 503 - 6555533
Inspection Request Scheduled For: Date: 11/13/2008 Pour Time: e
.o
Code # Inspection Description Confirm # Contact # Me a ge
300 Plumbing final 077912-01 503 -472 -1657 Y
Corrections /Comm- %ts /Instructions: a
1
r 1:
li
Ti
- t
ru
, S ❑ PARTIAL APPROVAL ___I] CANCEL ❑ NO ACCESS _
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: (14/ .
,/ Date: V It Phone #: (503) 718 -
_-,,-
,
CITY OF TIGARD -
\,...:* 4 !7/ .
BUILDING DIVISION PERMIT #: PLM2008.00418
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: . 10/28/2006
Phone: (503) 639-4171 11M/011ifil`
Inspection Requests (24 Hrs.): (503) 639-4175
PAGE: 6
INSPECTION WORKSHEET FOR DATE 10/31/2008 TIME: 7:00AM
SITE ADDRESS: 15196 SW KENTON DR CLASS OF WORK:
SUBDIVISION: s.
A riFORD OAKS NO 2 LOT #: 106 TYPE OF USE:
PROJECT NAME: WORNATH
DESCRIPTION: Bathroom remodel.
C
OWNER: WORNATH, HARRY PHONE #: 03-472-1657
5.0-3,655.5533
CONTRACTOR: HOLLINGSWORTH PLUMBING PHONE If;
Inspection Request Scheduled For: Date 10/31/2008 Pour Time:
Code # Inspection Description Confirm # Contact # Message
320 Plumbing rough-in 077490-01 603.620-7785 N
Corrections/Comments/Instructions:
‘ [XL PASS 7 PARTIAL APPROVAL 7 CANCEL E NO ACCESS
n FAIL I I CALL FOR INSPECTION 0 ADDITIONAL FEES ASSESSED
Inspector: (ThAii.A.-J iA \I vve- Date: f0131 1 0 Phone #: (503) 718-
„_ ,