Permit CITY OF TIGARD ff DEVELOPMENT SERVICES PLUMBING PERMIT
P ERMIT #: PLM2001 -00255 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/18/01
SITE ADDRESS: 12030 SW LINCOLN AVE PARCEL: 2S102AB -00902
SUBDIVISION: KIMBERLY ADDITION ZONING: R -7
BLOCK: LOT: 002 JURISDICTION: TIG
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: 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: 40 ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Install 40' of water service
FEES
Owner:
Type By Date Amount Receipt
SAKATA- ANNAND, EDNA N + PRMT CTR 6/18/01 $72.50 27200100000
ANNAND, JOHN D II 5PCT CTR 6/18/01 $5.80 27200100000
12030 SW LINCOLN AVE
TIGARD, OR 97223 Total $78.30
Phone 1:
Contractor:
EARL WISDOM
3966 NE GARFIELD
PORTLAND, OR 97212 REQUIRED INSPECTIONS
Phone 1: 503 - 528 -9551 Final Inspection
Reg #: LIC 122960
PLM 26 -620pb
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:
V2 / Permittee Signature:
4 ^
Call (503) 639 175 by 7:00 P.M. for an inspection needed the next business day
Plumbing Permit Application ` .
Date received: 6 : fg. -0 Pe 'tft0 o/ - =
; - 1 , City of Tigard
1 g 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: I Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
ex 1 & 2 family dwelling or accessory 0 Commercial/industrial 0 Multi- family 0 Tenant improvement
0 New construction 0 Addition/alteration /replacement 0 Food service 0 Other:
JOB SITE INFORMATION FEE SCHEDULE (for special information use checklist)
Job address: i ■RO30 ‘Ii G /6/Cet 4 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: I Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City/county: I ZIP: Each additional bath/kitchen
Description and h6cation of work on premises: i a ! , Site utilities:
Gi�io1 / Catch basin/area drain
r Est. date of completion/inspection: Drywells/leach line/trench drain
PLUM CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: L�sf L 1 /e/aow - icr, Manholes
Address: ?914 — ./d Rain drain connector
City: i I State:I_ZIP:97a-/ 7— Sanitary sewer (no. lin. ft.)
" .'"'" :42$ I Fax: I E -mail: Storm sewer (no. lin. ft.)
CCB no.: / I Plumb. bus. reg. no:d76, - -6,.9D1Ce Water service (no. lin. ft.)
0
City/metro lie. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer
Print name: �; - L 4.//S1So7P1 Date: 6, Mr / Backwater valve •
CONTACT PERSON Basins/lavatory
Name: Esr'i-Z W / 5 DeM Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone:503 -380 -915. Fax: E -mail: Expansion tank
Fixture/sewer cap
Name ( print): .1jt/.U,¢,J/p Floor drains/floor sinks/hub
Garbage disposal
Mailing address: Hose bibb
City: I State: I ZIP: Ice maker
Phe ebb Z - !i d.?. '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
Urinal
Name: 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. Notice: This permit application Minimum fee $
0 Visa 0 MasterCard if a permit is not obtained Plan review (at _ %) $
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $
Expires TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 440-4616 (6A0/COM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE - TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavato 16.60 for each utility connection)
ry 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 PLEASE COMPLETE:
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
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
Other Fixtures (Specify) 16.60 Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine ,
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3"
Sewer - each additional 100' 46.40 4" ,
Water Service - 1st 100' 55.00 Water Heater
�5'� 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
5
'*PLAN REVIEW 25% OF SUBTOTAL
•
Required only if fixture qty. total Is > 9
TOTAL $' Q 2T
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow o 7�
Prevention Device, which is $36.25 + 8% state surcharge.
' New Commercial Buildings require plans with isometric or riser diagram and
plan review.
i:\dsts \forms\plm- fees.doc 10/10/00
3c/P
•
■CITY OF TIGARD BUILDING INSPECTION DIVISION MST
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
// � BUP
Date Requested 4o-/ AM PM BLD
Location /to jG• 7r.✓ Girt/ Suite MEC
Contact Person e4t / Ph 3vv- f b's PLM Z.e
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access: W S Gr FPS
Foundation l /
FtgDrain P�tr ��- Li�.rn �i•
- Crawl Drain Inspection Notes! SGN
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Misc:
Final
PASS PART FAIL
Post & Beam
Under Slab
To Out
at
anitary Sewer
Drains
S PART FAIL
• - . ANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA / ? Aproach /Sidewalk Dat / 9 ^ 0 / Inspector / � �. // fo v e E
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.