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CITY OF TIGAR1 PLUMBING PERMIT
DEVELOPMENT SERVICES PERMIT#: PLM2004-00254
13125 SW Hall Blvd., Tigard, OR 972',3 (503) b39-4171 D .TE ISSUED: 6/8/200
PARCEL: 2S 111 CC-10900
SITE ADDRESS: 15870 SV. GREENS WAN
SUBDIVISION: SUMMERF!`.LD NO.2 ZONING: R-12
BLOCK: SOT: 136 JURISDICTION: TIG
CLAS: OF WORK: OTR GARBAGE DISPOSALS: MOB',I_E HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
()C,;UPANCY GRP: R2 FLOOR DRAINS; TRAPS:
STORIES. WATER HEATER_ CATCH BASINS:
_ FIXTURES _ LAUNDRY TRAYS: SF FAIN DRH1P:"-
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER F1'!TURES:
TUB/SHOWERS: SEWER L,'NE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of residential b2ckflcw prevention device.
Owner
FEES_ _
- — —'� I Description Date Amount
TANNER, FAN I'LUMBI I'crn.il I-cc 6/8/2004 $36.25
15870 SW GW ENS WAY
TIGARD, OR 97224 ; i AXj 8%State Surrharl 6/812004 $2.90
Total $39.15
Phone :
Contractor:
A14CTIL PLUMBING INC'
16900 SW MERLO RD
BEAVER FON, OR 97008 REQUIRED INSPECTIONS
RP/Backflow Preventer
Phone: 503-642.7321 Final InspE--tion
Reg #: LIC 24184
I'LM 26-162PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR.
Specialty Codes and all other anp!i,_able laws. All work will, be done in accordance with approved
plans This permit will expire if work 13 not started within 80 days Of issuance, or if work is suspended
for more than 180 days. ATTENTION: Oregon law requires you ic, follow rules adopi;id by the Oregon
Utility f!otification Center. Those rules are set forth in OAR 952-0001-OU10 througr OAR
952 0001-010( . You may obtain copies of these rules or direct questions to OUNC by calling (503)
246.6699.
sued By: �� 1,041 17f+ f Permittee Signature: V
Call (503)639 417 i by 7:00 P.M. for an inspection needer' the next business day
10ildiraM_ Fixtures
11.ainbing Permit Application
City of Tigard 7DatcP3y
$ d f( Pemut No (,t1 V'Ot�3
13125 SW Hall B vd..Tigard,OR 97223
Phone: 503.639.4171 Fnx: 50:598.'960 Othsr Pe mit No,
24•Hour Inspection Line: 503.639.4115 �''� ® See Page 2 rot
Internet: www.ci.tigard,ULUa 1:;;!jfieCidethOd: / f� Supplemental Inrorinatlun
TYPE. 9F WORK FEE* SCHEDULE
13 New construction ❑Demolition For special information use checklist.
�— - - ---- - Description i QtyEa. Total
ddition/alicration/teplacemPnt ❑Other: _ _ New 1-2-farrdy dwellings(Includes 100 ft.for each utility connection)
CATEGORY OF CnN_i RucnoN SFR(1)bath 249 20
and 2-family dwelling Commeicial/industrial SFR(2)oath 350.00
Accessory building ❑Multi-family SFR(3)bath -_ 399.00
-•---- - --- — Each additional bath/kitchen 45.00
❑Maur builder ❑Other: R.) Page 2
JOB ;i''E INFORIIIATION AND LOCATION Site utilities `
Job site address: Catch basin or area drain 16.60
City/State/ZIP: Drywell,leach line,or trench drain 1660
Suite/bldg./apt.no.: Project name: - . / Footing drain(no linear t,: ) Page 2
- - I�CLt/I ' Manufactured home utilities 111.00
Goss street/directions to job site. '—
Manholes 16.6C
Rain drain connector 16.60
Sanitary sewer(no.linear ft.:_� Page 2
Storm sewer(no.linear.ft.:_) Page 2 _
Subdivision: Lot no.: Waa:r service(no.linear ft.: ) Page 2
-- --- — Fixture or Item
Tax map/parcel no.:
Absorption valve 16.60
DE RIPTION 01' WALKBackflow preventer --� Page 2
- Backwater valve 16.60
art- - - -- ---
Clothes washer 1660
---- -- -/ /'✓/ — aw. 5 - — Dishwasher i P ;00
Drinking fountain 16.60
'
C]'PROPERTY OWNER d ENAYr
- ----- _-_ _.-- ----- _ --- Eje:tor/sump 16.60
Name:
-__ Expansion tank 16.60
Address: Fixture/sewer cup 16.60
City/State/ZIP: Floor drain,Foor sink/hub 16.60
-
Phone: - ----------- __1 i a. 1 i --- Garbage 'sposal 16.60
( )— _ u_
APPLICANT --�+ - (] 4TACT PERSON Ice
bib 16.60
CO,
- --- -=—�— �_ - Ice maker 16.60
Business narle: " �/ Interceptor/grease trap 16.60
Contact name: Medical gas(value:$ ) Page 2
Address: `� Primer 16.60
--
1 ity/Stata`ZIP: Roof drain(commercial) 16.60
- - - Sir.k/basird oratory 16.60
Phone:( ) -( )
Fax:
•— -- - -- - -- Tub/sAowerishower pen 16.60
E-mail: Urinal 1660
CONTRACTO Water closet 16.60
') -� Wa16.60
Business name: l�'1)/L,.�z ��m� ter heater/ - _
��LL, Other: ~
Address: - (,C) L� �
City/State/Zlp of/L !V Subtotal
-1=--� Minimum permit fee 572 50 (_ -
Phone:( l 2 - Z - Fax:( ) - Residential backflow minimum permit fee $36 25 `P
- r Plan review (25%of permit fee)
CCB Lic.: Plumbing Ltc.
�� -- s Siete surcharge(8%of permit fee) l�
Authori,,:d signsturc 4 TOTAL PERM I IT FEE
r--- -
Print name: L(� �j�L D to 4, " This permit application expires if a permit Is not obr,{ned��tthin
180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board
iNBuilding�Permm\Pt.MF.PetnitAppdoc rant 440-4616T001MCONVWEB1
Plumbing Permit Application - City of Tigard '
Page 2 - Supplemental Information
Fee Schedule: _ _ Residential Fire Suppressien Systems:
--- Qty Fee(cu) Total - -^- ----
Site Ttilities_ _ Square Footage. Permit Fee:
Footing drain•1"100' 55.00 0 to 2,000 $115.00
-�" -- 600 S I%00001 to 3,
Footing drain-each additional 100' 46.40 2, ---------- -
3,601 to 7,200 $210.00
Sewer-Ist 100' 55.00
_ _— 7,201 and greater —_ 5309.00
Sewer-each additional 100' 46.40
Water Service-1at100' 55.00 _ Medical Gas Systems:
Water Service-each additional 100' .06.40 -"
��/aliilatloll: Permit
Storm&Rain Thain-1st 100' 55.00 - � i-it Fee:
$I 00 to$5,000.00 Minimum fee$7250
Storm& Main Drain-each additional 100' 4640 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for each
I,iixture or help Qty. Fee(ea) Total additional$100.00 or fractiun thereof,to and
including$10,000.00.
Commerc d Flack Flow Prevention fh'ricr ar.-ui $10,001.00 to$25,00000 $148.50 for the first$10,000.00 and$1,54 for
Residential Backflow Prevention Device each additional$100.00 or fraction thereof,to
minimum permit fee 536.25) and includin $25,000.00.
Rain Drain,single frmily dwelling r,s 15 $25,001.00 to 550,000.00 $379.50 for the first$25,000,00 and$1 45 for
Inspection of existing plumbing or - each additional$100.00 or fraction thereof,to
s ecially requested ins e,:tions-per hour _ 72 51) and including$50,000.00.
Subtotal: $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
each additional$100.00 or fraction thereof.
Fixture Work:
Are you capping, moving or replacing existing fixtures.' If
"yes",please indicate work performed by fixture. Failure to
ac-urateh•report fixtures could result in increased sewer fees*.
uantit by(ri.xtvre)Work Performed
Fixture Type: Replace
Nen, Moved Existing Capped Comments regarding fixture work:
llapu�tr}"Dont
[lath -Tub/Shower - -- ---- ---
-Jacuzzi/Whirlpool
Car Wash -Each Stall �-- -- -- - i ---
_-
-Diive Thru -- ---- --- -- -
C'u idor/Water Aspirator --------------- - "--
Dishwasher -Commercial
Drinking Fountain _ _ -- -- --------- --Eye Wash
Floor Thain/sink .2" `----
3" — — ---
Car Wash Drain
Garbage -Domestic
Disposal -Commerttel *Ni)i..: If the fixture work under this permit results in an
-Industrial
Ice Mach./Refs .Drains increase of sewer EL`Us,a sewer permit will he issued and
Oil Separator Gas Station — feet assessed for the sewer increase must he paid before the
Rec Vehicle Dump Statwa plumbing permit can be issued.
Shower -Gang
-Stall
Sink -Bar/Lavatory Quantify Total
-Bradley _
•commercial - —" Isometric or riser diagram is required if fixture yunntit%
-Service — total is>9.
Sv.imining Pool Filter
Washet -Clothes
Water Extractor — _ Plan Review
Water Closet-Toilet _ — Plan review is required if fixture quantity total is A.
Urinal
Other Fixtures:
i\Building1Permiu11_M-PmnitApp doc 303
CITY OF TIGARD 24-Hour
BUILDING Inspection Line: (503)a5 MST
INSPECTION DIVISION Business Line: (503)
BUP
Received �l Date Requested AM_-_ _PM__ BUR -_-
Location __ 7U Suite MEC
Cantat,t Person ���;..�,� Ph S7 ) - tM [� 1 '
Contractor__ _ Ph SWR _
BUILDING Tenant/Owner — ''----V_ 4 J ELC
Footing ELC —
Foundation Access:
Ftg Drain ELR -- -
Crawl Drag
Slab Inspection Notes: SIT
Post&Bbam -
Shear A ichors -
Ext Sheath"Shear -
Int Sheath/Shear
Framing _---�- -- -
Insulation
Drywall Ivgning e '> 1 �- .. ----- --- - _- --------
Firewall
Fire Sprinkler
Fire Alarm , _-
Susp'd Ceiling
Roof ----
Other: _
Final �i� -mac G• G �_�
PASS PART FAIL
Fost&deem •Lam,
Under Slab
Rough-In
Water Service — --- j
Sanitary Sewer LAA � � +� p--ti -
Rain Drains --
Catch ir+/Manhole
Drain
Storm Drain '- —'--
(S er P n - -
•na
_PART FAIL_ - -- - i
HANICAL _ --------.------ — -
Post&Beam
Rough-In - -- -- -- ---
Gas Line
Smoke Dampers — - --- ----—— —
Final
PASS PART FAIL — --- --- -"
ELECTRICAL - -
Service
Rough-In -- —. - — -- --- -- -- — -
UG/Slab
Low Voltage - ------------ - -- __.-_.__
Fire Alarm
Final U Rein,3pection fee of$ _required before next Inspection. Pay at Oity Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE _ Please call for reinspection RE-_ _ Unable to inspect-no accPas
Fire Supply Line
ADA (VY' -Approach/Sidewalk Darts-- Inspector --- �" Ext - -
Other:---.-----__.....
Final DO NOT REMOVE this Inspection record from the Job site.
PASS PART FAIL