Permit CITY OFTIGARD
�,, ;,, DEVELOPMENT SERVICES PLUMBING PERMIT I
��� I I PERMIT # • PLM97 -0008
''� . 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639.4171 DATE . i SSUED,° 01413/97
PARCEL: 1S134DD -00700
SITE ADDRESS— : 10895 SW TIGARD ST
SUBDI V LSION. ° ° ° , " _ . . , ., , , , , . :,. ,.. . ; _ , ; ZONING,:,-- R-4.5-1,:
BLOCK LOT _
CLASS OF WORK °° :ALT GARBAGE DISPOSALS °: 0 MOBILE HOME SPACES.: 0
TYPE OF USE. -SF ,.WASHING MACH ...0. BACKFLOW PREVNTRS..: 0
OCCUPANCY GRP °. :R3 FLOOR DRAINS 0 TRAPS ° ° ° ° ° ° ° °°° ° ° °.: 0
STORIES • 0. , . WATER, HEATERS; . ., 0. ,. CATCH BASINS : 0
FIXTURES LAUNDRY TRAYS 0 SF RAIN DRAINS - 0
SINKS ° ,.., URINALS °° ° ° ° „ 0._, .GREAS TRAPS• , . ,, 0 .
LAVATORIES ° 0 ' ' OTHER FIXTURES • 0
.TUB /SHOWERS , ° 0 , 1 SEWER „LINE (ft ) ° 7 °, ,,.1.00:, ; ,i,
WATER CLOSETS ° °: 0 WATER LINE (ft)...: 0
DISHWASHERS . : 0_, RAIN DRAIN _ (ft ) . _ :-,.,,, _. 0 ,
Remarks: Sewer line
Owner: . , . FEES
SCOTT BERNHARD type amount by date recpt
10895. SW TIGARD, ST , , PRMT $ • _30 °00 JSD 01/13/97 97- 288821
5PCT $ 1.50 JSD 01/13/97 97- 288821
TIGARD_OR 97223
Phone #;
Contractor ,
OWNER
Phone #: $ 31.50 TOTAL
Reg #° ° : 99999 .
REQUIRED INSPECTIONS
This permit is issued,subject_to the,, r ;egulat,io,ns,cantained » ,.;_
Tigard Municipal..Cade,,,State of, Ore. Specialay ,,.Cades:andall,other,.,. �, _
:applicable, laws.',,,R11 ,done, in. accordance with....: _ .
• approved •plans.. This permit wiU:,, expire• if work is of ,started , , .. . ,
Within . days of , ,issuance,Ar,;,if..work,;is su -•ndeiJ,or;aore'. • . , _
than '180 days. „ . . ,
Permittee Signat�F G._ � � __ .• •
. I/ _
Issued B ° /i ce ' N _ _�
'V , .
Cal l f or , i.ns.pection — .839 -4175
CITY OF TIGARD
Plumbing Application Recd By
13125 HALL BLVD. Commercial and Residential Date Rec'd r 1 - 13 - 9 . 4
TIGARD, OR 97223 Date to P.E.
Date t
(503) 639 -4171 Pemmt sT PLiD^�i�-600S
h Print or Type yp Related SWR s 5,- 2 9- . 1
Incomplete or illegible applications will not be accepted Called OTC.
Name atDevelopme uprolect FIXTURES (Individual) QTY PRICE AMT -
Job �� (Z-K i4-A R -d Sink 9.00
Address strut Address . Suite Lavatory 9.00
/6 �
45 5� I I A/e Tub or Tub/Shower Comb.
9.00
Bldg 9 City /St a Zip Shower Only
9.00
972.._3 Water Closet 9.00
Name
Dishwasher 9.00
Owner Mailing Addre • Suite Garbage Disposal
9.00
Washing Machine 9.00
City/State Zip Phone Floor Drain 2" 9.00
Name - - -- -- 3- 9.00
Occupant Maig Suite Water Heater 9.00 -
Laundry Room Tray - 9.00 •
City/State Zip Phone Urinal - -• -
9.00 .. .
Name - C l _ _ / Other Fixtures (Specify) 9.00 - - - '
nJ L�l - . 9.00
Contractor Mailing Address Suite
9.00
City/State Zip Phone
- ' ' 9.00
I .9.00. -
Oregon Const. Cont. Board Lic.a Exp. Date 9.00
Atittt+dl Copy of -
Current Plumbing Lic. 9 Exp. Date . - Sewer - 1st 100- 9.00 - 30--
Licensee 30.00
COT Business Tax or Metro s Exp. Date" - each additional 100' 25.00
Water Service -1st 100' 30.00 '
Name Water Service - each additional 200' -- 25.00
Architect Storm a Rain Drain - 1st 100' 30.00
or Mailing Address g,., ;e Storm & Rain Drain - each additional 100' 25.00
• Mobile Home Space 25.00
Engineer I City /State up Phone Commeraal Back Flow Prevention Device or Anti- 25.00
Pollution Device
Neat,* work New 0 Addition 0 Alteration 0 Repair O Residential Backflow Prevention Device' 15.00
to be done: Residential Non- residential 0
Any description of work Y Trap or Waste Not Connected to a Fixture I 9.00
_ � Catch Basin I 9.00
12 Li , • Insp. of Existing Plumbing 40.00
ct oenhr
use of Speaih Requested Inspections 40.00
g or property
Rain Crain. single family dwelling 30.00
Proposed use of (r Grease Traps 9.00
building or property I
QUANTITY TOTAL
Are you capping . moving or replacing any fixtures? Yes 0 No 0 Isometric or riser aiagram is required a duanty Total is > 9
(tf yes see back o form) 'SUBTOTAL
I hereby ackno - ge that I have read this a • • lication. that the information --
given is corre at I am the owner or - .1 orizec agent of the owner. and 5% SURCHARGE �
that clans s . • rued, . • - in comoliance ith C - • • n State Laws. - ) , 5//
' ' / /
/i / r • Agent Date / PLAN REVIEW 25% OF SUBTOTAL I
/- ro _ ? 7 � only d'iWmur qty. total s ?
TOTAL
: ;ontact Person Nam = 3d `�
- � 11 1� I � 73 3 'Minimum permit fee is 525 • 5% surcharge. except Residential Backflow
G /11/1 1Z G / Prevention Device. which is 515 • 5% surcharge 3/ 50
i :ldststplmapp.doc 8/96
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PLEASE COMPLETE AS APPROPRIATE TO PROJECT:
Fixtures to be capped, moved or replaced Qty
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet ' Dishwasher S/3' '
Garbage Disposal
Washing Machine
Floor Drain 2"
4° -
Water Heater - - - - - - - --
Laundry Room Tray
Urinal -- - - - -- - -- - - -- -- -
Other Fixtures (Specify) -
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COMMENTS REGARDING ABOVE:
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