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10190 SW INEZ STREET 0 cc 0 N C/? 1 I'F 10190 SW Inez Street CITY OF TIGARD BUILDING INSPECTION DIVISION MST 24-Hous, Inspection Line: 639-4175 Business Line: 639-4171 --- � BLIP 1 � Date Requesied--Z/-- - AM __PM ^ 3LD Location_/ w_ /t _— Suite MEC Contact Person K�v�^- Pb PLM 041 Contractor Ph SWR BUILDING v Tenant/Owner ELC T 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 _ - _— Roof Misc: --- Final PASS PART FAIL _-- FIE UMB Post& Beam - — Under Slab Top_Qy anitary Sewer ' Drains A , S ) PART FAIL "JIMNANICAL� 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$ req,jire:i before next Inspection. Pay at City Hall, 13125 SW Hall Blvd Catch Basin ]Ple ise call for reinspection RE_ ( ]Unable to inspect-no access Fire Supply Line ADA Approach/Sidewalk Dated Inspector Ext Other - Final PASS PART FAIL. DO NOT REMOVE this inspection record from the job site. BUP'- Building Permit ELC - Electrical Permit Inspection Description Date Passed By Inspection Description Date Passed By ' Vx ting/Setback _ Underground cover _ Foundation walls Wall cover I~ooting drain_ _ Ceiling cover Waterproof bsmt walls J Electrical rough-in Slab _ _ Electrical service Crawl drain Electrical final Underfloor insulation _ Post/beam structural Shear walls/anchors ELR - Restricted Energy Permit Roof nailingIns ection Description Date Passed B Firewall _ Low voltam _ Tilt-up panel Electrical final Masonry/Reinforcement Framing MFG-Structure set-up MEC - Mechanical Permit _ Insulation _ Inspection Description Date Passed B Drywall nailing Post/beam mechanical Suspended ceiling Gas line Engineered soils Mechanical rough- n Welding Lab Final I Fire damper _ Concrete Lab Final Duct work Bolting Lab Final _Smoke detector Fire roofin Lab Final _ Mechanical final Structural observation -- Final inspection PLM _Plumb ug Peruvit Ins ection Description Date Passed B ' BUP -- Fire Protection S stem Permit -- - _. Plumbing underslab ection—Description Date hissed liInCrawl drain Sprinkler uderNor/slab — Post;beam plumbing Sprinkler rough-ii _ Plumbing top-out Sprinkler final _.__ RP/backflow preventer Fire alarm final _ Rain drain Storm drain _ Water service SIT - Site Permit Sanitar sewer _ Inspection Description Date Passed By Culvert/catch basin Footings_ Pump/fill septic tank _ Foundation walls Plumbing final Sprinkle- supply line;, Sprinkler underfloorhilab - C'utch basin/Manhole SWR - Sewer Permit Engineered soils _ �l Inspection Description Date Passed B Engineering acceptance..._ Sanitary sewer Final inspection Final inspection _ INSPECTION RFcmi) - [3l►[', PLM, SWR, ELC, ELR, MEC;, SIT PERMITS CITYOF T I GA R D PLUMBING PERMIT _ Lr DEVELOPMENT SERVICES PERMIT#: PL_M200000409 13125 EW Hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 11!1!00 SITE ADDRESS: 10190 SW INEZ ST PARCEL: 2S111BC-02200 SUBDIVISION: TIGARDViLLE HEIGHTS ZONING: R-3.5 BLOCK: LOT: 020 JURISDICTION: TIG CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES: TYPE OF USE: SF WASHING MACH: BACKFLOW/ PREVNTRS: OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS: STORIES: WATER HEATERS: CATCH BASINS: FIXTURES LAUNDRY TRAYS SF RAIN DRAINS: ^ SINKS: �0 URINALS: GREASE TRAPS: LAVATORIES: OTHER FIXTURES: TUB/SHOWERS: SEWER LINE: ft WATER CLOSETS: WATER LINE: 40 ft DISHWASHERS: RAIN DRAIN: ft Remarks: Replacement of 40'of water service. owner: FEES ^- Type By Date Amount Receipt SCHMIDT, TROY M + SUSAN L -- — -- 10190 SW INEZ ST PRMT CTR 11/1/00 $72.50 27200000000 TIGARD, OR 97224 5PCT CTR 11/1/00 _ __$5.80 27200000000 Total $78.30 Phone 1: Contractor: MR ROOTER OF PORT LI\ND PORTLAND SERVICES INC 15033 SE MCLOUGHLIN BLVD #344 REQUIRED INSPECTIONS MIL.WAUKIE, OR 9726-i Phone 1: 503-653-5301 Water Service Insp Reg #: LIC 9834E Final Inspection PLM 3-434PB This permit is issued subject to the regulations contained in the Tigard Municipal Cede, 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 riot 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 Cfility Notification Center. Those rules are set forth in OAR 952_-0001-0010 through OAR 952.-0001-OObO. You may obtain copies of these rules or direct questions to OUNC by cal"Ag ( Q3) 246-1987. Issued By: I _ Permittee Signature: Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next usiness day fy CITY O F T I G A R D ------- .. MECHANICAL PERMIT DEVELOPMENT SERVICES PERMIT#: MEC2000-00505 13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 12/26/00 PARCEL: 2S111 BC 02200 SITE ADDRESS: 10190 SW INIcZ ST SUBDIVISION: TIGARDVILLE HEIGHTS ZONING: R-3.5 BLOCK: LOT: 020 JURISDICTION: TIG CLASS OF WORK: ALT FLOOR FURN: EVAP COOLu.'11i: TYPE OF USE: SF UNIT HEATERS: VENT FANS: OCCUPANCY GRP: VENTS W/O APPL: V1---NT SYSTEMS: STORIES: BOILERS/COMPRESSORS HOODS: FUELTYPES 0 3 HP: COMES. INCIN: GAS 3 15 HP: COMML. INCIN: MAX INPUT: BTU 15 30 HP: REPAIR UNITS. FIRE DAMPERS?: 30 50 HP: WOODSTOVEG: GAS PRESSURE: 50 + HP: CLO DRYERS: FURN < 100K BTU: 1 AIR HANDLING UNITS OTHER UI`ITS: FURN >=100K BTU: <= 10000 cfm: ^,qS OUT`' FTS: 10000 cfm: Remarks: Installation Of Gas Furnace Owner: -- --- —�_ --- - --FEES �— SCHMIDT, TROY M 4 SUSAN L Type By — Date Amount Receipt 10190 SW INEZ ST PRM- CTR 12/26/00 $72.50 2720000000 TIGARD, OR 97224 5PCT CTR 12/2.6/00 $5.80 272000000C Phone: 1'otai $78.30 ----- --- — --- Contractor: JACOBS HEATING +A/C 4474 SE MILWAUKIE AVE PORTLAND, OR 97202. REQUIRED INSPECTIONS Mechanical Ins.,) Phone:503-2.34-7331 Final Inspection Reg#:LIC 1441 EXPIRE[ This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Coles and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is no+ started within 180 days of issuance.. or if work is suspended for more than 180 days. A FI ENTlnN: Oregon law requires you to follow rules adopted in the Oregon Utility Notification Center. Those rules are set fora, in OAR 952.-001-0010 through OAR 952-001-0080. You may obtain copies of these rules or direct questions to OUNC by UA calling (503)246-9189. Is3ue By: �1X�--=_ Permittee Signature: Call (503 639-4175 by 7:00 P.M. for inspections needed the next business day BUP - _Building Permit ELC - Electrical Permit 4 inspection ik-scri Von Date Passed By Inspection Description Date Passed B� Footing/Setback Underground cover Foundation walls — Wall cover — Footin drain -Ceiling cover _ Waterproof bsmt walls Electrical rough-in _ Siab Electrical service_ — Crawl drain Electrical final Underfloor insulation_ — Post/beam structural Shear walls/anchors ELR - Restricted Energy Permit Roof nailing In ion Description_ Date Passed B Firewall _ Low voltage Jilt-up panel Electrical final Masonry/Reinforcernent Framing --- -- ' MFG-Structure sec-up MEC - Mechanical Permit _ Insulation Infection Description Date Passed UX Drywall nailin Post/beam mechanical Suspended ceiling _ Gas line Engineered soils Mechanical rough-in_ Welding Lab Final Fire dam r _ Concrete Lab Final _ Duct work Bolting Lab Final -_ Smoke detector Fire roofin Lab Final _ _ Mechanical final Structural obseri ation Final ins ection _- — — PLM - Plun.jbingPermit _ inspection Description_ Date Passed B BUP -- Fire Protection System Permit Plumbing, underslab inspection Description Date Passed B _ _ Crawl drain _ Sprinkler underfloor/slab Post/beam lumbin Sprinkler rough-in _ Pluinbin top-out Sprinkler final RP/backflow reventer _ Fire alarm final Rain drain Storm drain _.. Water service SIT - Site Permit Sanitary sewer _- Inspection Description Date Passed By Culvert/catch basin Footings Pum /fill se tic tank Foundation walls Plumbing final Sprinkler supply lines _ S rin'.der underfloor/slab Catcn basin/Manhole SWR - Sewer Permit _ Engineered soils Inspection Description Date Passed B En in_eerin acceptance Sanitary sewer Final inspection — — Final inspection INSPECTION REICORD - BUP, PLM, SWR, ELC, ELR, MEC, SIT PERMITS CITYO F T'I GA R D PLUMBING PERMIT DEVELOPMENT SERVIDES PERMIT#: PLM2002-00128 13125 SW Hall Blvd.,Tigard, OR 97223 (503) 639-4171 DATE. ISSUED: 6/2.7/02 SITE ADDRESS: 10190 SSV INEZ ST PARCEL: 2S111E3C-04700 SUBDIVISION: SCHMIDT MLP2000-00005 ZONING: R-3.5 BLOCK: LOT: 001 JURISDICTION: TIG CLASS OF WORK: OTR r4RBAGE DISPOSALS: MOBLE HOME SPACES: TYPE OF USE: St- WASHING MACH: BACKFLOW PREVNTRS: OCCUPANCY GRP: R3 FLOOR DRAINS: TRAPS: STORIES: WATER HEATERS: CATCH BASINS: FIXTURES _ LAUNDRY TRAYS: SF RAIN DRAINS: ^SINKS: �y URINALS: GREASE TRAPS: LAVATORIES: OTHER FIXTURES: 1 TUBISHOWERS: SEWER LINE: 100 ft WATER CLOSETS: WATER LINE: ft DISHWASHERS- RAIN DRAIN: ft Remarks: Connect existing house to newly installed sewer lateral. Installing less than 100 feet of sewer line and reversing the plumbing under the house. _ FEES Owner: -_ Type By Date Amount Receipt TROY SCHMIDT PPMT CTR 6/27/02 $105.00 27200200000- 10190 SW INEZ 5PCf CTR 6/27/02 $8.40 27200200000 TIGARD, OR 97223 _ _ _ __ Total $113.40 Phony 1: 503-624.0366 Contractor: DITCH MASTERS SEWERS. INC. 8965 SF_ DIVISION PORTLAND, OR 97266 REQUIRED INSPECTIONS Phone 1: 503-777-8289 Sewer Inspection V` Reg #: LIC 132751 'LM/Underfloor PLM 26-444P8 Final Inspection This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all ocher applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is riot started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules ariopted 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 calling-(503) 246-1987. Issued By: ✓--l0 t :; �t _Jt c( C r_- Permittee Signature: ;�/(—"" w Call (503) 639-4175 by 7:00 P.M. for an inspection needed the neXt bt,siness day Plumbing Permit Application "Datereccived: Permit no.: City of Tigard Sewer permit no.: Building permit no.: Address: 13125 SW hall IliNd,Tigard,OR 97223 City of7igard Phone: (503) 639-4171 1'roJecUappl.no.: E ire ate: Fax: (503) 598-1960 Date issued: By� Peceipt no. Lang use approval: Case file no.: Payment type: y 1 I &2 family dwelling or accessory a Commercial/industrial U Multi-family U Tenant in:pro eniew U New construction U Addition/alteration/replacement U food service J t)lhel 11 1 i Job address: /0/�LCJ i-✓ /'��' ' - 1)cscri!►tion ljt`'. hec(ca.) Total '\., New I-and 2-family d"ellings only: Bldg.nSuite n0.: (includes IIID ft.foreach u111ill Connection) Tax map/tax tax lot/accoent no,: SFR(1)hatli Lot: Bluck: Subdivision: SFR(2)bath Project name: SFR(3)bath City/county: ! pr 4 ZIP: Each additional bath/kitchen Description and I anon wor on remises: ✓�''C _ Siteutlllties: � Catch basin/area drain _ Est.date of completio"'it�pection: Drywells/leach line/trench drain _ Fcxiting ain(no.lin. 1't.) _ 1 Manufactu,,d home utilities Business name: ►✓�+ ' -1+ C Manholes Address: c 41 01') _ Rain drain connector City: , • c•,; State' ZiP: Sanitary sewer�(o in. Phone: ?7)-&- ,j f Fax:771—vZj E-mail; Sloan sewer(no.lin. ft.) CCB no.: /� Plumb.bus.reg.no: r� y Water service(no.lin.ft.) Fixture or item: City/metrolic.no.; ,_s?41?U Absorption valve _ Contractor's representative signature: Backflow preventer Prim name; .? �': , ) - Da c: l Backwater valve Basins/lavatory _ Clothes washer Name: c c: N�,_ _ �, -E —�` -- Dishwasher _ qdid re'.4s' - Drinking fountain(s) _ City; _ State: ZIP: Ejectors/sump Phone: Fax: E-mail: Expansion tank •ixture/se wer c.p Name(print): j �� .` Floor drains/Qoor sinks/hub Garbage disposal _ 1 M ltul ng address: ZO� 0 d.' Hose bibh City: State: Ice maker None; E-mail: Interco torIgrease tra Owner installation/residential maintenance only: The actual installation Primer(s) will be made by me or the maintenance and repair made by my regula- Roof drain(commercial) _ employee on die property I own as per ORS Chapter 447. Sink(s) basin(s), lays(s) Owner's signature: _ Date: Sum Tubs/shower/shower pan Urinal Name: Watercoset — Address: Water heater City: _ — --- State: ZIP _ Other: -- Phone:� Fax: E-mail: Not all Jurisdictions accept,:rcait cards,plean tali►uridm iclion for mote inin ation Notice:This permit applicat %) ion Minimum tee........... $ _yam..... U Visa U MasterCard expires if a permit is not obtained Plan review(at � 9i.) $ _ State surcharge(896) ....$ Credit card number:.,._-_ _ �1 within 180 days after it has been ��— pRplte+ TOTAL . $ ----- - - accepted as complete. Name or cardholder as shown on credit card S Cardhnldtr dgnomre -- - Amount 4 O-M16(6ASatt'UM) PLUMBING PERMIT FEES: - PRICE TOTAL. 'We-W1 and 2-family dwellings unly: j FIXTURES (individual) CITY ea AMOUNT ` (includes all plumbing fixtures In I PRICE TOTAL Sink 16.60 the dwelling arid the first100 ft. CITY (ea) AMOUNT Lavatory 16.60 for each utility connection) One(1)bath _ $249.20 Tub or Tub/Shower Comb. 16.60 Two 2 bath 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 -_J TOTAL Laundry Tray 16.60 Washing Machine 16.60 Floor Drain/Floor Sink 2" 16.60 3.1 16.60 - PL_EAJE COMPLETE: q^ 18.60 Water Heater O conversion O like kind 16.60 l _ Quantlt b Work Performed Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/ ermit. Capped MFG Home New Water Service 46.40 Sink MFG Home New San/Storm Sewerr 46.40 Lavatory Tub or Tub/Shower Hose Bibs 16.60 Combination Roof Drains 16.60 Shower Only Drinking Fountain 16.60 Water Closet Other Fixtures(Specify) 1660 Ul nal Dishwasher Garbage Disposal _ Laundry Room Tray Washing Machine _ _ Flonr Drain/Sink: 2" 1 Sewer-1 st 100' -- 55.00 J.F -- Sewer-each additional 100' 46.40 4" Water Service-1st 100' 55.00 Water Heater Water Service-each additional 200' 46.40 Other Fixtures _ (Spec Storm 8 Rain Drain-1s1 100' 55.00 - Storm&Rain Drain-eech additional 100' 48.46 Commercial Back Flow Prevention Device 46.40 - Residential Backflow Pre:entlon Device' 27.55 "- Calrh Basin 16.60 Inspection of Existing Plumbing or Specially 62.50 Retested lnspectionslnsp©coonsper/hr COMMENTS REGARDING ABOVE: Rain Drain,single family dwelling 65.25 Grease � - Grease Trays 16.60 ------- - - QUANTITY TOTAL �` r Isometric or r ser diagram is required If -- - ----�l--+---- Y - Quantity Total Is >B -- "SUBTOTAL -- 8%STATE SURCHARGE -- -------- ------- -- "PLAN REVIEW 25°/x.OF SUBTOTAL Re uired only If fixture yly total Is>B TOTAL � l "Minimum permit tee is$72 50+87,state surrhargt,except Residential Backflow Prevention Device,which Is$36 25+8%state surcharge "All New Commercial Buildings require 2 sets of plans with Isometric or riser diagram for plan review. I:\dsts\forms\plm-fees.doc 12/26/01 SEWER CONNECTION PERMIT CITY OF TI GARD DEVELOPMENT SERVICES PERMIT#: SWR2002-00147 1312E SW Hall Blvd., Tigard, OR 9722.3 (503) G39-4171 DATF ISSUED: 6%27/02 SITE ADDRESS; 10190 SW INEZ ST PARCEL: 2S111BC-04700 SUBDIVISION: SCHMIDT MLP2000-00005 ZONING: R-3.5 BL OCK: LOT: 001 JURISDICTION: 1 IG TENANT NAME: USA NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1 TYPE OF USE: SF NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Remarks: Connect existing house to newly installed sewer lateral. Septic tank must be properly abandoned, either pumped &filled or removed and inspected. Owner. FEES —_---- TROY SCHMIDT 10190 SW INEZ Type By Date (kmount Receipt TIGARD, OR 97223 PRMT CTR 6127102 $2,300.00 27200200000 INSP CTR 6/27102 $35.00 27200200000 Phone: 503-624-0366 Total $2,335.00 Contractor: Phone: Reg #: Required Inspections Sewer Inspection Septic,Tank Filled This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires 180 days from the date .,sued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer laterals. :f the sewer is not located at the measurement given, the installer shall prospect 3 feet In all directions from the distance given. If not so located,the installer shall purchase 3"Tap and Side Sewer' Perm Issued by: )r ;_r' C i Permittee Signature: Call (503) 639-4175 by 7:00 P.M. for an Inspection needed the next business day CITYO F T I G,AR D __PLUMBING PERMIT DEVELOPMENT SERVICES PERMIT#: PLM2000-00409 13125 SW hall Blvd., Tigard, OR 97223 (503) 639-4171 DATE ISSUED: 1111/00 SITE ADDRESS: 10190 SW INEZ S'r PARCEL: 2S111BC-02200 SUBDIVISION: TIGARDVILLE HEIGHTS ZONING: R-3.5 BLOCK: LOT: 020 JURISDICTION: TIG CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME. SPACES: TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 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 CLOSE FS: WATER LINE: 40 ft DISHWASHERS. RAIN DRAIN: ft Romarks: Replacement of 40'of water service. FEES Owner: _ -- Type By Date Amount Receipt SCHMIDT, TROY M + SUSAN L RMT CTR 11/1/00 $72.50 21200000000 10190 SW INEZ ST TIGARD, OR 97224 SPCT_CTR 11/1/00 $5.80 27200000000 Total $78.30 Phone 1: Contractor: MR ROOTER OF PORTLAND PORTLAND SERVICES INC 15033 SE MCLOUGHL-IN BLVD #344 MII_WAUKIE, OR 97267 _ REQUIRED INSPECTIONS_ Phone 1: 503-653.5301 Water Service Insp Reg #: LIC 98346 Final Inspection Pl_M 3-434PB 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 952-0001-00.10 through OAR 952-0001-0080 You may obtain copies of these rules or direct questions to OUNC by calling ( 03) 246-1987. Issued By: %(raze) Permittee Signature: Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next Lusiness day Plumbing Permit Application / Date received: Permit no.: LM OCO� �OYD City of Tigard y g Sewer permit no.: Building perniit no.: Address: 13125 SW Nall Blvd,'figard,OR 97223 City of Tigard Phone: (503) 639-4171 Project/appl.no.: Expire date: Fax: (503) 598.1960 Date issued: (B,/: Receipt no.: Land use approval: Case file no.: Payment type: )4H &2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement U New construction U Addition/alieration/replacement U Food service U Other: INFORMATIONJOB SITE Job address: tj e at _ Descri tion Qty. f e (ea.) 'total Bldg. no.: _ Suite no.; NeH I-and 2-fami1y dvvelfings only: (include,.100 ft.forcach litilily cunncction) Tax map/tax lot/account no.: _ SPR(1)bath Lot: Block: I Subdivision: SFR(2)bash Project name: SFR(3)bath - City/county; ZIP: Each additional bath/kitchen Des c 'ption an locatio of work on premises: t, ele Illu 0,1SfteutBltles: A t Catch basin/area drain Fst ate of completion/inspection: Drywells/leach line/trench drain Footing drain(no.lin. ft) Manufactured home utilities Business name: i Cr Manholes Address: c- '3 s' . ���, . Rain drain connector City; , t C- State: ZIP: Sanitarysewer(no.lin.ft.) Phune:�,�;?3 �{ Fax: Email: Storm sewer(no.lin.ft.) CCB no.: i 3 2a-ql Plumb,bus.reg.no: Water service(no. lin.ft.) City/metro tic.no.: Fixture or Item: Contractor's representative signature: Absorption valve -- - -•— Back flow reventer Prim name: hate: Backwater valve CONTU11'PERSON Basins/lavalory Name: , Clothes washer Address; rJ �� — Dishwasher L Drinking fountain(s) City: ti. ,2 ,tate:0, ZIP: o Ejectors/sump Phonc�7�7� (� Fax. I -mail: Expansion tank Fixture/sewer cap Name(print):-- C 3 floor drains/floor sinks/hub ailing address: ,�) Garbage disposal MQ Nose hibb City: i.-,iii State: ZIP: Ice maker Phone: fax E-mail: Interceptor/ reale trap _ (honer installation/residential maintenance only: The actual installation Primer(s) will be made by me or the masntenance and repair made by my regular Roof drain(commercial) employee of the property I own as per URS Chapter 447. Sink(s),basin(s),lays(s) _ (hvner's signature: _ Date: Sump Tubs/shower/shower pan _ Urinal Name: Water closet _ Address: Water heater City: ^~ — State: ZIP: Other: - Phone: Fax: E-mail: Total Na all)urisdictioru accept credit cods,please call}udcdictim for nxxr inform96)ation, Notice:This permit application Minimum fee............ ) $ 7 � U Visa U MasterCard expires if a permit is not obtained Plan review(at _ $ Credit card number � _ — / - /— within 1110 days after it has been State surcharge(8%)....$ -�-�-�•�- - Expires TOTAL . $ Nam,of cardlxrldn u shown on credit card accepted as complete. """"""""""" S Cardholder signature Amount 41f1A616(SMCOM) PLUMBING PERMIT FEES: — PRICE TOTAL New 1 and 24amily dwellings only: FIXTURES individuals__ QTY ea AMOUNT (includes all plumbing fixtures In PRICE TOTAL Sint. 1660 the dwelling and the flrst100 ft. QTY (ea) AMOUNT ifi 60 _for each utility-c_onn_ection J — Lavatory� One 1 bath_ $249.20 Tub or fub/Shower Comb 1fi fit} — Two 2 bath $350.OU Shower Only —� 16.60 Three 3 bath $399.00 — Water Close[ 16.60 SUBTOTAL —__— Urinal 16.60 _ _ 8%STATE SURCHARGE Dishwasher J— 16.60 PLAN REVIEW 25%OF SUBTOTAL TOTAL Garbage Disposal 16.60 ------- ---- - _ _ _^. -- _-- Laundry Tray 16.60 vi,ashing Machine 16.60 Floor Drain/Floor Sink 2" 16.60 v PLEASE COMPLETE: 3° 16.6^ 4"— -- Water Heater O conversion O like kind 16.60 __ Quantic b Work Performed Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removedl ermit. Capped MFG Home New Water Service 4640 Sink MFG Home New San/Slorm Sewer 46.40 Lavatory _ Tub or'rub/Shower Hose Bibs 16.60 Combination Roof Drains 16.60 Shower Only — Drinking Fountain 18.80 Water Closet _ — Urinal Other FixtureE;'specify) 16.60 _ 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 — Other Fixtures Water Service-each additional 200' 46.40 Sed Slonn R Rain Orain-1st 100' 55.00 _ Storm 8 Rain Drain-each additional 100' 46.40 — — Commercial Back Flow Prevention Device 46.40 - -- Residential Backflow Prevention Device27,55 — Catch Basin 16.60 P _ inspection of Existing Plumbing or Specially 72.50 Requested Inspectionspar/hr COMMENTS REGARDING ABOVE: Rain Drain,single family dwelling 65.25 Grease Traps — 16.60 ---- — — QUANTITY TOTAL Isometric or riser diagram Is required it Quantity Total Is >9 ----- 'SUBTOTAL --- 8%STATE SURCHARGE A -- — ---— — "PLAN REVIEW 25%OF SUBTOTAL Required only if fixture qty total Is>9 TOTAL S *Mlnlmuni permit fee Is$72 50+8%state surcharge,except Residential Backflow Prevention Device,which is$36 25+8%state surcharge 'All New Commerelsl Buildings require plans with Isometric or riser diagram and plan review i:\dst•1\forms\plm-fnes.doc 10/10/00