Permit A - CITY OP TIGARD PLUMBING PERMIT
PERMIT #: PLM2000 -00308
,.I+i DEVELOPMENT Tigard, ) 639 -4171 DATE ISSUED: 8/21/00
13125 SITE ADDRESS: 10900 SW PARK ST PARCEL: 2S103DA -03900
SUBDIVISION: ZONING: R-4.5
BLOCK: LOT: JURISDICTION: TIG
CLASS OF WORK: ADD 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: Installation of residential backflow prevention device.
FEES
Owner:
Type By Date Amount Receipt
DENNIS WANLESS PRMT CTR 8/21/00 $25.00 27200000000
PO BOX 23453 5PCT CTR 8/21/00 $2.00 27200000000
TIGARD, OR 97281
Total $27.00
Phone 1: 624 -9307
Contractor:
OWNER
REQUIRED INSPECTIONS
Phone 1: RP /Backflow Preventer
Reg #: Final Inspection
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 callin• (503) 246 -1987.
Issued y: J Permittee Signature: , `� / /, , X11
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
,
CITY OF TIGARD Plumbing Permit Application Plan C eck #
13125 SW HALL BLVD. • -. f ' Commercial and Residential Recd
TIGARD, OR 97223 Date Rec'd 8 ��
(503) 639 -4171 Date to P.E.
Print or Type Date to DS
Incomplete or illegible applications will not be accepted Permit # rc /49019
Related SWR #
Called
Name of Development/Project FIXTURES (individual) QTY PRICE AMT
J Sink 11.50
Address Street Address Suite Lavatory 11.50
1 t l [ G 62,4) 5 Tub or Tub /Shower Comb. 11.50
Bldg # City /State Zip Shower Only 11.50
t�a(n T/6-4 )) 9 70Z-3 Water Closet 11.50
E/✓�I// l/f/ffC1ll4ss Urinal . 11.50
Owner ailing Address X1.0, 8 p Suite Dishwasher 11.50
Z-S VS - S Garbage Disposal 11.50
City /State Zip Phone •
Laundry Tray 11.50
- 776 4 / 972- / _ 62 -v-�/ 3 0�
Name ame Washing Machine /Laundry Tray 11.50
'SA-Pvt-o ,(-5 .4- 6-1_ Floor Drain/Floor Sink 2" 11.50
Occupant Mailing Address Suite 3" 11.50
4" 11.50
City /State Zip Phone
Water Heater 0 conversion 0 like kind 11.50
Name Gas piping requires a separate mechanical permit.
h(.i) Ai/E4- MFG Home New Water Service 32.00
Contractor Mailing Address Suite MFG Home New San/Storm Sewer 32.00
Hose Bibs 11.50
Prior to permit City/State Zip Phone Roof Drains 11.50
issuance, a copy
Drinking Fountain 11.50
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if Other Fixtures (Specify) 15.00
expired in COT Plumbing Lic. # Exp. Date
database '
Name
Architect Sewer - 1st 100' 38.00
-- - or Mailing Address - Suite Sewer - each additional 100' 32.00
Water Service - 1st 100' 38.00
Engineer City/State Zip Phone
Water Service - each additional 206' 32.00
Describe work to be done: Storm & Rain Drain - 1st 100' 38.00
New Q� Repair 0 Replace with like kind: Yes 0 No 0 Storm & Rain Drain - each additional 100' 32.00
Residential Q'" Commercial 0
Additional description of work: Commercial Back Flow Prevention Device 32.00
Residential Backflow Prevention Device' 19.00
Catch Basin 11.50
Are you capping, moving or replacing any fixtures? Insp. of Existing Plumbing or Specially Requested 50.00
Yes 0 No OV Inspections per/hr
If yes, see back of form to indicate work performed by Rain Drain, single family dwelling 45.00
fixture. FAILURE TO ACCURATELY REPORT FIXTURE Grease Traps 11.50
WORK COULD RESULT IN INCREASED SEWER FEES. QUANTITY TOTAL
I hereby acknowledge that I have read this application, that the information Isometric or riser diagram is required if Quantity Total is > 9 /
given is correct, that I am the owner or authorized agent of the owner, and *SUBTOTAL �l
th.t plans submitted are in co •Iiance with Oregon State Laws. 9 ,
afire of Owner /:.. t Date
i
`; 8% SURCHARGE Qd
O
•i", tact Person Name l hone
•el /S //( -A46.5 62-q---93D7 "PLAN REVIEW 25% OF SUBTOTAL
1 BATH HOUSE $178.00 Required only if fixture qty. total is > 9
O
2 BATH HOUSE $250.00 TOTAL • G
3 BATH HOUSE $285.00 - -
(This fee includes all plumbing fixtures In the dwelling and the first *Minimum permit fee is $50 + 8% surcharge, except Residential Backflow Prevention
.100 feet of sanitary sewer storm sewer and water service) Device, whirl is $25 + 8% surcharge
"All New Commercial Bulldin r riser diagram and
- plan review.
l:ldstsformslplumapp.doc 11/18/99
PLEASE COMPLETE:
Fixture Type Quantity by Work Performed
New Moved I Replaced Removed /Capped
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Urinal
Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
te a.
I: tdstsVormslplumapp.doc 11/18/99