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Permit CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT PERMIT #: PLM2007 -00449 TIGARD DATE ISSUED: 10/4/2007 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S103C6 - 02600 SITE ADDRESS: 12165 SW MARION ST ZONING: R-4.5 SUBDIVISION: WILLAMETTE NO.2 LOT: 029 JURISDICTION: TIG PROJECT: BERGSTROM Project Description: Connect existing house to sewer service, approximately 90'. Septic tank is to be pumped and filled. 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: SEWER LINE: 90 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS: RAIN DRAIN: ft Owner: FEES EDWARD A. BERGSTROM 12165 SW MARION Description Date Amount TIGARD, OR 97223 [PLUMB] Permit Fee 10/4/2007 $72.50 [TAX] 8% State Surcha 10/4/2007 $5.80 Phone : 503- 329 -7996 Total $78.30 Contractor: A AFFORDABLE SEPTIC SERVICE SOX 1130 WILSONVILLE, OR 97070 WI LSONVILL REQUIRED ITEMS AND REPORTS • WI Contact # : PRI 503- 969 -9548 FAX 503 -570 -0779 • Reg #: LIC 158246 • 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 r - - • - t question to OUNC by calling 503.246.6699 or 1.800.332.2344. Iss -d By: Peimittee 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 completion of the project. Approved plans are required on the job site at the time of each inspection. Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard Dat ve ( 0 ©� Permit No.: ,y i 7� (f 9 III • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review 0 . Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit No. e/ v...etaj 3 T I G A R D Inspection Line: 503.639 Date Ready/By: ` B See Page 2 for Internet: www.tigard- or.gov Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE El New construction El Demolition For special information use checklist Description I Qty. I Ea. 1 Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 El 1- and 2- family dwelling El Commercial/industrial SFR (2) bath 350.00 1:1 Accessory building ❑ Multi- family SFR (3) bath 399.00 12 Master builder Each additional bath/kitchen 45.00 ❑ O ther: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: /2 / 4 Su 5_ GV- M,a. h■ ; d 5t Catch basin or area drain 16.60 City /State /ZIP: T t V 11,. (Z o ` e _ 7 p 2-z ? Drywell, leach line, or trench drain 16.60 - Suite/bldg. /apt. no.: I 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.: `70 Page 2 55,0 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2 Tax map /parcel no.: Fixture or item Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer Page 2 41 %Vl ..11._.-- `A ) th. CiL 1(Vri_rl...\. . ��� J Backwater valve . 16.60 Clothes washer 16.60 - Dishwasher 16.60 ❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60 I @ y Ejectors /sump 16.60 Q Name: w 0. -d 4.. !� Pe .- ' /- cJ 7�'' Expansion tank 16.60 Address: / _ j r f (�, M c .... p_. /.a N S r _ Fixture/sewer cap 16.60 City /State/ZIP: Tlt __ r 0/ b N 9 2 x Z 3 Floor drain/floor sink/hub 16.60 Phone: (,-03) 2 2 9,., 7 9 94 Fax: ( ) Garbage disposal 16.60 ❑ APPLICANT ❑ CONTACT PERSON Hose bib 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 Phone: ( ) I Fax: : ( ) Sink/basin/lavatory 16.60 Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name: A_ 14 F p - d a..- b l€ 5",2_,0 t i C Water heater 16.60 Address: Other City /State /ZIP: n fLeALUVa Subtotal Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 7a ` CCB Lic.: +/ ..5" 8 z y 6 Plumbing Lic. no.: Plan review (25% of permit fee) Autho d sl e: State surcharge (8% of permit fee) g 0 . TOTAL PERMIT FEE . Print name: /5 /� ,e k s' / . d yyr I Date: / 6,707 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. 1:\Building\Permits\PLMF- PermitApp.doc 12/27/06 440 -4616 / M/WEB /� ��t�, " O� V 00 Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information . Fee Schedule: ' Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - l 100' 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 Sewer - 1st 100' / 55.00 3,601 to 7,200 $220.00 / 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: 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 Fixture or Item Qty. Fee (ea) Total 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 specially requested inspections - per hour 72.50 and including $50,000.00. 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. • Fixture Work: Plan Review 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 by (Fixture) Work Performed greater, except systems designed and stamped by licensed Fixture Type: Replace engineer. 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 Isometric or Riser Diagram 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\PLM- PermitApp.doc 12/27/06 _ .._ 7 . ...: : , -...• A.AFfoRDABLE setTic SERVICE P.O.BOX 1130 WILSONVILLE, OR 97070 (503) 9924929 FAX (0) 570-0779 www.aaffordablesepticsmoom . . CUSTOMERS ORDER NO. PHONE DATE ,-. NAME g'/I 27 7 ADDRESS . ii 6 c-S 5 - , 6.) , 71-1 A ,-/ , o J r' 1— . --- / - 2Z- - ri ,--) A_ SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE. RET'D. PAID 03 N4x7 QTY. DESCRIPTION PRICE AMOUNT "'AO /t. ...- e C.) 7e C. i ........_—..—..... _-- - , --, l . t ! d". f' TAX RECEIVED BY TOTAL All claims and returned goods MUST be accompanied by this bill. /mum/ To Reorder: THANK YOU 'L.') 800-225-6380 or robs.com CITY OF TIGARD - BUILDING DIVISION PERMIT #: PLM2007- 00449 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 10/412007 Phone: (503) 639 -4171 Inspection Requests (24 Hrs.): (503) 639 -4175 : -' `'I I INSPECTION WORKSHEET FOR DATE: 10/10/2007 TIME: 7 :01AM PAGE: 19 SITE ADDRESS: 12165 SW MARION ST CLASS OF WORK: SUBDIVISION: WILLAMETTE NO.2 LOT #: 0 ?9 TYPE OF USE: PROJECT NAME: BERGSTROM DESCRIPTION: Connect existing house to sewer service, approximately 90'. Septic tank is to be pumped and filled. OWNER: BERGSTROM, EDWARD PHONE #: 503 - 329-7996 CONTRACTOR: A AFFORDABLE SEPTIC SERVICE PHONE #: 503.9f99548 Inspection Request Scheduled For: Date: 10/10/2007 Pour Time: Code # Inspection Description Confirm # Contact # Message SOS Sanitary sewer 057333-01 503969 -9548 Y Ft' uaI Corrections/Comments/Instructions: d Putt-1w S,P'C 4 a G Ta,/N4 Y i - c: ' \A-vt. 1 utt- -e - RCc, e, b_--H-- 0,4,Le-ci G ary, P 6-- -7 X PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED Inspector: . ► 1 w\,..„. Date: I chi j o) 0'7 Phone #: (503) 718-