Permit PLUMBING PERMIT
CITY OF TIGARD PERMI ISSUED: 12/�8/95 121378
COMMUNITY DEVELOPMENT DEPARTMENT PARCEL: S 102CB -02300
13125 SW Hall Blvd. Tigard, Oregon 97223.8199 (503) 539 -4171
SITE ADDRESS...: 13200 SW PACIFIC HWY
SUBDIVISION • FREWINGS ORCHARD TRACTS ZONING: C -G
BLOCK • LOT •8
CLASS OF WORK..:ALT GARBAGE DISPOSALS.: 0 MOBILE HOME SPACES.: 0
TYPE OF USE •COM WASHING MACH • 0 BACKFLOW PREVNTRS..: 1
OCCUPANCY GR1=;..:B2 FLOOR DRAINS 0 TRAPS : 0
STORIES • 0 WATER HEATERS • 0 CATCH BASINS • 0
FIXTURES LAUNDRY TRAYS.....: 0 SF RAIN DRAINS • 0
SINKS • 0 URINALS • 0 GREASE TRAPS • 0
' LAVATORIES • 0 OTHER FIXTURES • 0
TUB /SHOWERS • 0 SEWER LINE (ft)...: 0
WATER CLOSETS..: 0 WATER LINE (ft)...: 0
DISHWASHERS • 0 RAIN DRAIN (ft)...: 0
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Remarks: Installinn backflow prevention device
Owner: - - - - -- -- FEES -• --
MILLIHAN MEDICAL CENTER type amount by date recpt
13200 SW PACIFIC HWY PRMT $ 25.00 B 12/28/95 95- 274374
SPCT $ 1.25 B 12/28/95 95- 274374
. TIGARD OR 97223
Phone #:
Contractor:
CONTRACTOR NOT ON FILE
Phone #: $ 26.25 TOTAL
Req #.. .
REQUIRED INSPECTIONS
This per.it is issued subject to the regulations contained in the RP /Back f l ow Pre _ —_
Tigard Municipal Code, State of Ore. Specialty Codes and all other Final Inspection _ __________
applicable laws. All work will be done in accordance with i __ __ _
approved plans. This oersit will expire if work is not started _ __ __, _ __`_____ •_.-
within 180 days of issuance, or if work is suspended for sore — _ _
_ _
than 180 days. _- - ._ -_�_ _ - -_.'- - -` __ -_ .-
Perm i t t e e Sic at u r e: � _ - - -- ±- - ----
`; Issued By : ' N.A.1/6,14.,-%- -- - -- - __I_ - -- - -- —
Call for inspection - 639 -4175
i
o
City of Tigard PLUMBING PERMIT APPLICATION Planck/Rec. #
13125 SW Hall Blvd. Permit # Pt../44 15
Tigard, OR 97223
(503) 639 -4171
MINIMUM $25.00 PERMIT FEE + ST. SURCHARGE
"'°" a New Single Family Residences Only
/"/"// 1/ /< Get-. A t (�s'•‘--]` it__
Address ❑ 1 BATH HOUSE $140.00 ❑ 2 BATH HOUSE $195.00
Job / ?, CO cS/1) /-/ {7 C M i ❑ 3 BATH HOUSE $225.00
Address arse.. zo Fee includes all plumbing fixtures in the dwelling and the first 100 feet
c."Aut 4� r 77g 3 of water service, sanitary sewer and storm sewer. See fees below.
''r"' Or nem d B- FIXTURES QTY PRICE AMT
Sink 9.00
Mniep Address Rem Lavatory 9.00
Owner Tub or Tub/Shower Comb. 9.00
atom. a. Shower Only 9.00
Water Closet 9.00
Nome (at deeden a eemeeseI Dishwasher 9.00
Occupant Garbage Disposal 9.00
"'''"o Adm . Flee. Washing Machine 9.00
Floor Drain 9.00
(Waste m Water Heater 9.00
Laundry Room Tray 9.00
IA Urinal 9.00
v 1 C,Cve ov% 68S S0 Other Fixtures (Specify) 9.00
9.00
Contractor
oWCSs SL/� i k ec/ 9.00
wow. ap 9.00
6 �' /12).•z-v, 7l fib- 97.7e Sewer 1st 100' • 30.00
stn. r+.v.a.me n.
col a°• r° No. Sewer - ea. Addit. 100' 25.00
996 7 7 Water Service 1st 100' 30.00
I hereby acknowledge that I have read this application, that the Water Service ea. Addit. 200' 25.00
information given is correct, that I am the owner or authorized agent of
the owner, that plans submitted are in compliance with State laws, that Storm & Rain Drain 1st 100' 30.00
I am registered with the Construction Contractor's Board, that the Storm & Rain Drain Addit 100' 25.00
number given is correct (If exempt from State registration, please
give reason below.) Mobile Home Space 25.00
Back Flow Prevention
Device or Anti- Pollution Device / 9.00
%vend. (.lees or au Any Trap or Waste Not
Connected to a Fixture 9.00
Describe work new 0 addition 0 alteration repair Catch Basin 9.00
to be done residential 0 non - residential 0 Insp. of Exist Plumbing 40.00/hr
Specialty Requested Inspections 40.00/hr
Existing use of
building or property Rain Drain, single family dwelling 30.00
Residential backflow prevention
devices 15.00
Proposed use of
building or property
'(Except residential backfiow
prevention devices)
NOTICE *Minimum Fee $25.00 SUBTOTAL
25
PERMITS BECOME VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF 5% SURCHARGE / Z5
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED
FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS
COMMENCED. PLAN REVIEW 25% OF SUBTOTAL
TOTAL 24 •2-
Special Conditions
Date issued by
Page No. 1 CASE HISTORY FOR CASE NO.: PLM95 -0378
MILLIKAN MEDICAL CENTER
•
13200 SW PACIFIC HWY -
03/04/99
Action Description Req/ Schd/ End/ Action Notes Disp By Update Upd
Code Sent Done Done Date By
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PLMA800 Case Finaled / / / / 12/29/95 APP GS 12/29/95 GES
PLMC003 Application received / / / / 12/28/95 PEND B 12/28/95 B
PLMC005 Permit Created / / / / 12/28/95 PEND B 12/28/95 B
PLMC060 (F) Issue permit / / / / 12/28/95 PASS B 12/28/95 B
PLMC750 RP /Backflow Preventer 12/28/95 / / 12/29/95 APP GS 12/29/95 GES •
PLMC799 Final Inspection • / / / / 12/29/95 APP GS 12/29/95 GES
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