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10685 SW Fairhaven Street
CITYO F I I G A R D PLUMBING PERMIT _
DEVELOPMENT SERVICES PERMIT#: PLM2001-00.,80
13125 SW Hall Bl✓d.. Tigard, OR 97233 (503) 639-4171 DAT[ IS;OED: 8/14/01
SITE ADDRESS: 10685 SW FAIRHAVEN ST PARCEL: 2S103DD-00404
SUBDIVISION: FAIRHAVEN COURT ZONING: R-3 5
BLOCK: LOT: 004 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USF.: 5F 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:
TUBISHOWERS- 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
MATYCHU'-;K, MICHAEL W+ VIRGINI PRMT CTR 8/14/01 $36.25 27200100000-
10665 SW FA'RHAVEN ST 5PCT CTR 8/14/01 $2.90 27200100000
TIGARD, OR 972?3 —
Total $39.15
Phone 1:
Contractor:
OWNER
REQUIRED INSPECTIONS
RP/Backflow Preventer
Phone 1: Final Inspection
Reg #:
This permit is issued subject to the regulations contained in the Tigard Municipa' 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 w;thin 180 days of issuan;e, 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 se+ 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: Permittee Signature:
Call (503) 639-4175 by 7:PV P.M. for an inspection needed the next business day
Plumbing Permit Application
Date received: Permitno.:
City of Tigard
Address: 13125 SW Hall Blvd,'I'igard,OR 97223 Sewer permit no.: Building permit no.:
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:
1
3 1 &2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement
U New cominu-tirm 'J,`Uldition/.tlleration/t-eplacemenl U Food service U Olhet:
11 1N FEE SCIIIIEDULE(for special h1roelillationjusec,
; , - DescriptionJob address: / (, 5 �4� G1ty. I ee(t a.) "Iota
Bldg.no.: I Suite no.:
Ne" 1 and 2 famih disc Ilia{s only.
- 0nc-lude�100 fl.foreachulifil}'comwelion)
Tax map/lax dol/account no.: SFR(1)bath
_Lot-. 13lock: �Stibdivision: SFR(2)bath
Project name: SFR(3)had, —
City/county: =P: a Each additional hath/kitchen
Description and location of work on premises: _ -__ Siteutilitles:
_ Catch basin/area drain
I A.date of completion/inspection: - Drywclls/leach line/trench drain
Footing drain(no. lin.ft.)
n — —
Manufactured home utilities
Business name: �7)(�i; ! /L Manholes
Address: Rain drain connector
City: State: UP: Sanitary sewer(no.lin.ft.) -
Phone: Fax: I E-mail: Storm sewer(no.lin. ft.)
CCB no.: _ Plun J.bus.reg.no:
Wale: service(no.lin. ft.) -
City/metro lic,no.: -- Fixture or item:
Contractor's representative signature: - Absorption valve
Print name. Date: — Back flow preventer —
Backwater valve
1 q Basins/lavatory
Name: (,,(,t, /�11 C Clothes washer
—�. Dishwasher
Address: (> SGv l /1///,i G't /G I — — —
Drinking fountain(s)
City: tj 6,1,;L-12 r) Stall Ejectors/sump
Pho :5Z3) 36i Fax: F-ImW: Expansion tank —
Fixture/sewer cap
Name(print): l} L s" — --�/� P o 11L Glen drains/flc sinks/hub
address: — - Garhag.;disppoosaall
Dose bibb
City: State: �;lP: _ Ice maker
Phone: Fax: Email: Inienxptor/grease trap
owner installation/residential maintenance only: The actual installation Primer(s) _
will be made by me or the maintenance and repair made by my regular Roof drain(commercial)
employee on thepro I/tw s Ix.. a�. r 447. Sink(s),basin(s), lays(s)
Owner's signatur . L` 'hl Date: d Sump _
7'ubs/shower%shower pan
NUrinal
Name: —�
---— ------- --- Water closet
Address: _ _ Water heater '^
City: __ State: - 'LIP: other: - ----- i— — —
Phone:— -- Y Fax: _ E mail -- -------- Total
NM all jurisdictions accept credit cards,please call jud-diction for more information Minimum fee................$
Notice:'nis pennit application
U Visa U MasterCard expires if a permit is not obtained Plan review(at — 46) $
Credit cud number: _— — within ISO days after it has been State surcharge(8%)....$
------. Name of cardholder u shown oncreditcad accepted es complete. TOTAL .......................$ 5_—
—�_ Cardholder signature Amount 440-4616(6100ICOM)
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 andd 2-famlly dwellings only: PRICE TOTAL
QTY ea AMOUNT (Includes all plumbing fixtures in AMOUNT
FIXTURES individualteal the dwelllnu and the firstl00 ft. QTY (ea)
Sink - for each utili connection $249.20
- - -" 16.60 One 1 bath
Lavatory _ _ $350.00
Tuh or Tub/Shower Comb. 16.60 - Two 2 bath $399.00
r- - 16.60 Three(3)bath
Shower Only -
Water Closet 16.60 _ SUBTOTAL
-- -- - 16.60 8%STATE SURCHARGE
Urinal _ PLAN REVIEW 25%0- F SUBTOTAL
'J- 16.60 - TOTAL -
Olshwasher _ -'-"-
Garbage Disposal
16.60 -
16.60
Laundry Tray _
Washing Machine 16.60
Floor Drain/Floor Sink 2"
- 16.60 PLEASE COMPLETE:
3- 16.00 -
4" - 16.60 quantit bb Work Performed
16.60 Fixture Type: New Moved Replaced Removed/
Water Heater O conversion O like kind Ca ed
Gas piping requires a separate mechanical -
ennit. 46.40 Sink
MFG Hrrrme New Water Service - Lavator - --
MFG Home New-m;'-,-,m Sewer
46.40 Tub or Tub/Shower
16.60 Combination
Hoca albs
16.60 Shower Onl
--
Roof Drains _ Water Closet _
Drinking Fountain 16'60 Urinal
Other Fixtures ISpecify) 16.60 Dishwasher
Garbs a Dis osal
Laund Room Tra
VI ashin Machine
Floor Drain/Sink: 2"
55.00 3.,
Sewer-1 sl 100' --
46.40 4
Sewer-each additional 100' Water Heater
Water Service-1st 100' 55.00 Other Fixtures
Water Service-each additional 200' 46.40 _ S ecl
55.00
Sto --
rm&Raln Drain-1st 100 _-_
46.40
Storm!r Rain Drain-each additional 100' - --
Coemarcial Back Flow Prevontlon Device 46.40 -
Resid,intial Backflow Prevention Device27.55
Catch Basin 16.00 _
2.50
Inn�3ctlon of Existing Plumbing or Specially 7erth
error COMMENTS REGARDING ABOVE:
Rr quested Ins eclions 65.25 -
� aln Drain,single family dwelling - -
16.60
Grease Irnps
- ---- _
QUANTITY TOTAL ---------
Isometric or riser diagram Is required If -_-- -
Quanllly Total Is > *SUBTOTAL _-------- ---
8%STATE SLIRCHARGE --
.'PLAIN REVIEW 25%OF SUBTOTAL
Required on! If fixture 9t total fs>9
TOTAL S
*Minimum permit fee Is$72 50+8%slate surcharge,except Residential Backflow
Prevention Device,which Is$36 25•fl%state surcharge
"All New commercial Buildings require pians with Isometric or riser diagram and
pian review
I:\dats\forms\plm-fees.doc 10/10/00
CITY OF TIGARD BUILDING INSPECTION DIVISION MST
24-Hour Inspection Line: 6, 4175 Business Liner 639- 1 ------ --- --_-____
BLIPDate Requested �� - Y _ _—ANM_ PM BLD
Location �( � � ?� � �'�`�.,/�«-T,� ;; � �'�- Suite MEC
Contact Person PhPLMl c: c
Contract,)r Ph (C,, /-3 _ SWR
BUILDING Tenant/Owner ELC y
Retaining Wall ELR
Footing Access:
Foundation FPS — —
Ftg Drain — SGN
Crawl Drain Inspection Notes: - ------
Slab _ SIT
Post&Beam
Ext Sheath/Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing _—
Firewall
Fire Sprinkler
Fire Alam
Susp'd Ceding — --- -
Roof
Misc --
Final
PASS PART FAIL — - —
PLUMBING }Y�
Past& Bearn ,.
Under Slab i� 1
Top Out
Water Servic6
Sanitary Sewer •.�_.�
Rain Drains
-
(PASS',l PART FAIL
M HANICAL
Post& Beam - _ -- - - - - - --—
Rough In
Gas Line - -
Smoke Dampers
Final -- -- - -
PASS PART FAIL
ELECTRICAL - -- - - - - -- - -
Service
Rough In
UG/Slab
Low Voltage
Fire Alarm _-� -- _._-- ---- --
Final
PASS PART FAIT. ------
SITE
-- --- ----— - ----- ---- ---SITE _
Backfill/Grading -- - - -- - ��-- -- -- —
Sanitary Sewer
Storm Drain [ ]Reinspection fee of$—,_ _ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd
Catch Basin I ]Please call for reinspection RE: [ ]Unable to Inspect -no access
Fire Supply Line -- -
ADA h . v ,
Approach/SidewcDate.k l V l idIns hector � Ext
Other — r —_� _
Final
PASS PART FAIL [DO NOT REMOVE this inspection record from the job site.
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