Permit CITY TIGARD PLUMBING PERMIT
C IA DEVELOPMENT SERVICES PERMIT #: PLM2001 -00139
- rI II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/6/01
SITE ADDRESS: 09725 SW SERENA WAY PARCEL: 2S114BA -10400
SUBDIVISION: COPPER CREEK STAGE 2 ZONING: R -4.5
BLOCK: LOT: 055 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
MORRISON, BRAD L + KARLYN M PRMT CTR 4/6/01 $36.25 27200100000
9725 SW SERENA WAY 5PCT CTR 4/6/01 $2.90 27200100000
TIGARD, OR 97224
Total $39.15
Phone 1:
Contractor:
OWNER
REQUIRED INSPECTIONS
e 1: RP /Backflow Preventer
Phone 1 . 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 ma copies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issue. : y: #7 ' Permittee Signature: . t i _ , J 1 10
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
i
• Plumbing Permit Application
Date received: y 6 /o/ Permit no.: pal,2oc /- 0o/ 32 A � �f City o Ti
permit �, °.� �! City Tigard Sewer permit no.: Building 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
T 1 & 2 family dwelling or accessory 0 Commercial/ind trial 0 Multi- family 0 Tenant improvement
0 New construction • Additio, teration/ lacement 0 Food service 0 Other: •
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: q-12.5 .5t" •.. A Wa-(,r Description Qty. Fee(ea.) Total
Bldg. no.: I Suite no.: J 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: C _ SFR (2) bath
Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Siteutilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells/leach line/trench drain
• PLUMBING CONTRACTOR , `; Footing drain (no. lin. ft.)
Manufactured home utilities
7 Business name: Q 1.13 . Manholes
Address: Rain drain connector
City: State: ZIP: Sanitary sewer (no. lin. ft.) __
Phone: 'Fax: 1E-mail: Storm sewer (no. lin. ft.)
cc') no.: I Plumb. bus. reg. no.
Water senile?, (no. lin. ft. j
City /metro lie. no.: Fixture or item:
Contractor's representative signature: Absorption valve
Back flow preventer /
Print name: Date: Backwater valve •
CONTACT PERSON :. . .. •.•, Basins/lavatory
Name: Clothes washer
Dishwasher
Address:
— Drinking fountain(s)
City: State: ZIP: Ejectors/sump
Phone: Fax: E -mail; Expansion tank
OWNER Fixture/sewer cap
Name (print): K r l B [V1 t r LSO fl Floor drains/floor sinks/hub
` Garbage disposal
Mailing address: Q'1 Sexe rto, kA- Hose bibb
City: Ti curd I State: CT I ZIP:o� 7 2 2� Ice maker
Phone: 5 d; (03a1 -1Z 2..( Fax: 1E-mail: µt p ¢U 2000 a(ns fInterceptor /grease trap
Owner installation/residential maintenance only: The actual installationC n Ptimer(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), in (co s), medal
Owner's signature: YY "A-4 oDy- -Date: q- - D ( Sump
Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: 'Fax: 1E-mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Minimum fee $ •.36 , . 2-5- Notice: This permit application Plan review (at _ %) $
O Visa O MasterCard expires if a permit is not obtained
Credit card number: / / within 180 days after it has been State surcharge (8 %) .... $ " ' g 0
Expires TOTAL $ 9 , is
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount • 440 -4616 (6A0/COM)
•
PLUMBING PERMIT FEES: •
PR ICE -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 flrst100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
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 PLEASE COMPLETE:
3" 16.60
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
•
16.60 Tub or Tub /Shower
Hose Bibs 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
Water Service - each additional 200' 46.40 Other Fixtures
(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
**PLAN REVIEW 25% OF SUBTOTAL -
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee' -. .- -e. except Residential Backflow
Prevention Device, arge.
** All New Commercia : u . -quire p ans with isometric or riser diagram and
plan review.
i:ldsts\forms\plm- fees.doc 10/10/00
z y •
CITY OF TIGARD BUILDING INSPECTION DIVISION MST
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP
,,Date Requested q' 3 AM PM BLD
Location f 7 Z f Sw .5.e 7eit way Suite • MEC
Contact Person Ph .57) - 37- z - .'PLM / - - ( ) /37
Contractor Ph SWR
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling ) & `n--
Roof
Misc:
Final
P ART FAIL
Post & Beam
Under Slab
Top Out
Water Service g44; 57 Sanitary Sewer 5'v'
Rain Drains
Fi -
gall PART FAIL •
- -- ICAL
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 - no access
ADA ��
Approach/Sidewalk � / V
Other Date 47/ Q / Inspector Ext
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.