Permit A CITY OF TIGARD PLUMBING PERMIT
& tVI ' DEVELOPMENT SERVICES MIT #: PLM1999 -00146
Al 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -41 'GI PARCEL: 2S111 AD -05500
UED: 5/7/99
SITE ADDRESS: 08750 SW PINEBROOK ST
SUBDIVISION: PINEBROOK TERRACE ZONING: R -4.5
BLOCK: LOT: 078 JURISDICTION: TIG
CLASS OF WORK: OTR 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
CULBERTSON, BESSIE A + CHARMIE APPL DRA 5/7/99 $15.00 99- 315192
8750 SW PINEBROOK MISC DRA 5/7/99 $0.75 99- 315192
TIGARD, OR 97224
Total $15.75
Phone 1:
Contractor:
PROGRASS LANDSCAPE SERVICES
29895 SW KINSMAN RD
WILSONVILLE, OR 97070 REQUIRED INSPECTIONS
Phone 1: 682 -6076 RP /Backflow Preventer
Reg #: LIC 00006136 Final Inspection
PLM 11558
EXPIRED
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 forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0080.
Yo nlay obtaih \
L i es of these rules or direct questions to OUNC by calling (503) 246 -1987.
Is ued By: LI,41%C'.l'l...` Permittee Signature: i //, I`i / i� ia
Call (503) 63 -4175 by 7:00 P.M. for an inspection needed the next busi • ess day
CITY OF TIGARD RECEIVED Plumbing Permit Application ......----
eck -
13125 SW HALL BLVD. r v ,- 7 1 999 . Commercial and Residenti Rec' y
TIGARD, OR 97223 Date Rec'd <i --
(503) 639 -4171 COMMUNITY DEVELOPMENT Date to P.E.
Print or Type Date to D T -
Incomplete or illegible applications will not be accepted Permit# c.N 19`19 60/0
Related SWR #
Called
Name of Development/Project FIXTURES (Individual) QTY ' PRICE >t AMT.=
Job (! in it- , t_/Y)t . t- 0 LA-l.{. C S! -yL Sink 9.00
a
Address Street Address Suite Lavatory 9.00
ff 7 5 C U PIY1 flQ IC - Tub or Tub/Shower Comb. 9.00
Bldg # City /State Zip Shower Only 9.00
_ nq met r✓, 4
Name Water Closet 9.00
S tL yn rr Dishwasher 9.00
Owner Mailing Address Suite Garbage Disposal 9.00
Washing Machine 9.00
City /State Zip Phone Floor Drain/Floor Sink 2° 9.00
La - di/9
Name 3" 9.00
(IVY) 6 4" 9.00
Occupant Mailing Address Suite Water Heater 0 conversion 0 like kind 9.00
_ Gas piping requires a separate mechanical permit.
City /State Zip , Phone Laundry Room Tray 9.00
Urinal 9.00
Name Other Fixtures (Specify) 9.00
Pro Gr ctsrS 9.00
Contractor Mailing Address -Suite P f
Z 9S Sr1.4) bns r'riG.et. 682-' % 9.00
Prior to permit City/State Zip Phone Sewer - 1st 100' 30.00
issuance, a copy l o Lt k5T)L LiL G2 976.7 6 to &Z - (c o7/o Sewer - each additional 100' 25.00
of all licenses are Oregon Const. Cont. Board Lic.# Exp. Date
required if 6/34e Water Service - 1st 100' 30.00
expired in COT Plumbing Lic. # Exp. Date Water Service - each additional 200' 25.00
database Storm & Rain Drain - 1st 100' 30.00
Name Storm & Rain Drain - each additional 100' 25.00
Architect Mobile Home Space 25.00
or Mailing Address Suite Commercial Back Flow Prevention Device or Anti- 25.00
Device
City/State Zip Phone ' ''
Engineer ty P � -��� = - AR) al Backflow Prevention Device' I 15.00 15 pp
rogation timing devices require a separate
Describe work to be done: restricted energy permit.)
New 0 Repair 0 Replace with like kind: Yes 0 No 0 Any Trap or Waste Not Connected to a Fixture 9.00
Residential 0 Commercial 0 Catch Basin 9.00
Additional description of work:
LAS-j--n. Lk 'of-Le C u p.. ) ue C J ttc U CLU Lf C, Insp. of Existing Plumbing 40.00
per /hr
tile" L'L L B 90. hLYiA•- S'S t[yvl . Specially Requested Inspections 40.00
per/hr
Rain Drain, single family dwelling 30.00
Are you capping, moving or replacing any fixtures?
Yes O No O Grease Traps 9.00
If yes, see back of form to indicate work performed by
QUANTITY TOTAL
fixture. FAILURE TO ACCURATELY REPORT FIXTURE
Isometric or riser diagram is required if Quantity Total is > 9
WORK COULD RESULT IN INCREASED SEWER FEES. *SUBTOTAL
I hereby acknowledge that I have read this application, that the information 15 OD
given is correct, that I am the owner or authorized agent of the owner, and 5% SURCHARGE
that plans submitted are in compliance with Oregon State Laws. 75
Signature of Own /Age Dale * *PLAN REVIEW 25% OF SUBTOTAL
T sr I q9 Required only if fixture qty. total is > 9
,-- . '
�j
TOTAL /5
o ` - C In Person Name Phone '
*Minimum permit fee is $25 + 5% surcharge, except Residential Backflow
Prevention Device, which is $15 + 5% surcharge
* *All New Commercial Buildings require plans with isometric or riser diagram
and plan review
I: \dsts\plumapp.doc 7/2/98
PLEASE COMPLETE:
Fixture Type :Quantity .by Work Performed
New ' Moved I : Replaced . Removed /Ca
Sink
pp
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain /Floor Sink 2"
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
I:Wsts\plumapp.doc 7/7/98