Permit (3) CITY OF TIGARD PLUMBING PERMIT
"COMMUNITY DEVELOPMENT `' "} Permit#: PLM2020-00285
Date Issued: 7/29/2020
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 OG 2/ yvj o Parcel: 2S109AC00300
Jurisdiction: Tigard
Site address: 14665 SW 133RD AVE
Project: BOSLEY Subdivision: None Lot: None
Project Description: 350 ft.of sanitary sewer. Connecting existing dwelling to public sewer. 8/21/2020: REPRINT permit to add(1)
ejector pump to sewer system.
Contractor: SUPERIOR UNDERGROUND LLC Owner: BOSLEY REVOCABLE LIVING TRUST
6400 SE 101 ST AVENUE SUITE 3 14665 SW 133RD AVE
PORTLAND, OR 97266 TIGARD, OR 97223
PHONE: 503-750-0020 PHONE:
FAX:
FEES
Quantity Description Date Amount
350 If Sanitary Sewer 07/28/2020 $175.10
Specifics: 1 12%State Surcharge- 07/28/2020 $21.01
Plumbing
Type of Use: SF 1 ea Ejectors/Sump 08/21/2020 $25.02
Class of Work: ALT 0 12%State Surcharge- 08/21/2020 $3.00
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $224.13
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. 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 the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to C by calling 503.232.19872. or 1.800.332.2344.
Issued By: ✓!1/Y fit" R �_ Permittee Signature: aA// e72 i0/—!7
G (ST ..0
Call 503.639.4175 by'7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
Building Fixtures RECEIVE FOR OFFICE USE ONLY
Cit of Ti and t+ �} Received c
_ r �' ,AuL1 ryy-1} Date/By: (f� ) J-P) )/"� PemtitYa.: % � r9,1 ,.�,,�(�
( 13125 SW Hall Blvd.,Tigard,OR 97223 1 GU4t plan Review
G��1 (/ems�.5
Phone: 503.7182439 Fax: 503.598.1960 Other Remit No.:
Inspection Line: 503.639.4175
CITY OF TIG�1RL Date/By:
TIGARI7- t n.n E," r. Date Ready/By: Jugs: I3 See Page 2 for
. Internet: www.tigald-Or.gov MAI fied/Methed' " Supplemental Information
'I YP1Z (11' 9VOR14 ---- I FEE'. SC1tMUTE
❑ New consnuetion El Demolition For voila!'information use ctrerk(ist
1 - ----- + -- Description I. Qty. j Ea. 1 Total
i ldditionit.'tctationJric pi cu.ennent Other.
❑ New 1-2-family dwellings(includes 100 ft.for each utility connection) 1
' CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
l-and 2-family y dwellingSFR(2)bath 437.78
CI
El Accessory buildingSFR(3)bath 500.32
0 Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑ Other:
Fire sprinkler( sq.ft.) Page 2
'JOB SITE INFORMATION AND-LOCATION Site utilities:
Job site address: I LIColo J SI,J 133`� Ave Catch basin or area drain 18.76
,.( Drywell,leach line,or trench drain 18.76
City/State/ZIP: ""-'�3 f 0 �'1 Z.�3 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear it: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.:
Backflow preventer 31.27
,', , "" g r Backwater valve 12.51
DE6GRIP'PION-o ;WORK
�,j,-�a _ i Clothes washer 25.02
fTtr$v� 'J ec d"- ( S�L-"2- r- 5'?+°S`k-e- `^. Dishwasher 25.02
�� 7 V EC/_ 77Af('- f X /7 Drinking fountain 25.02
Ejectors/sump 1, 25.02 -L$t 4°-2--
PROPERTY o'WNER "2 :V0, D TENANT Expansion tank 12.51
- - Fixture/sewer cap 25.02
Name:
� is Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
,APPLICA F , CI_ ON CONTACT PER Interceptor/grease trap 25.02
Eli
Business name: Medical gas(value:$_) Page 2
Primer 12.51
Contact name: 9,r re,.,6,� �C-4.-�!" Roof drain(commercial) 12.51
Address: `--'( Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:(303)75-0 --ca-e.'2 0 Fax: :( ) Tub/shower/shower pan 12.51
E-mail: 5-"C L'-o r u--Aele-,9)y0,,,..-8 LLL. 9,rl te2;(. co...".. Urinal 25.02
Water closet 25.02
CONTRACTOR Water heater 37.52
Business name:
Sue et)c9d- ( v t Li_ci Waterpiping/DWV 56.29
Address: &L Oo Sr- (of S Apr.,. ip... - Other: 25.02
/o 2&6, Subtotal aS�i', -
City/State/ZIP: wr��e� ��/� Q7
Phone:(53) 7 3-0 •- c3ea`Z Fax:(yp.y) ,903 - j z Minimum permit fee: $72.50
CCB Lie.: Li CI 110 Plumbing Lie P no.: 2cr2 yC Plan review (25%of permit fee)
State surcharge(12%of permit fee) ��,fitt
Authorized signature: 7 - TOTAL PERMIT FEE rp f 6ry ,
Print name: '(-D v( ,�+ Date: e }'�V This permit application expires if a permit is not obtained within 180 days
�+4 after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
1:1Euilding\Permits\PLMU-PermitApp.doc 10/01/D9 440-4616T(I 0/02/CCM/WEB)
i +r CITY OF TIGARD PLUMBING PERMIT
�'! ' COMMUNITY DEVELOPMENT Permit#: PLM2020-00285
Date Issued: 7/29/2020
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S109AC00300
Jurisdiction: Tigard
Site address: 14665 SW 133RD AVE
Project: BOSLEY Subdivision: None Lot: None
Project Description: 350 ft.of sanitary sewer. Connecting existing dwelling to public sewer.
Contractor: SUPERIOR UNDERGROUND LLC Owner: BOSLEY REVOCABLE LIVING TRUST
6400 SE 101ST AVENUE SUITE 3 14665 SW 133RD AVE
PORTLAND, OR 97266 TIGARD, OR 97223
PHONE: 503-750-0020 PHONE:
FAX:
FEES
Quantity Description Date Amount
350 If Sanitary Sewer 07/28/2020 $175.10
Specifics: 1 12%State Surcharge- 07/28/2020 $21.01
Plumbing
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $196.11
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.Issued By: Permittee Signature: < �1
i /
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept In a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
Building Fixtures RECEIVE 9 [t IR OFFICE use Oy l.v
Received
City of Tigard Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 J U L 2020 Plarat�Review 7' 7�dt► �7J` �mal.� lxb
• 11, Phone: 503.718.2439 Fax: 503.598.19 non Review
Other Permit No:
Inspection Line: 503.639.4175 �ITY OF TIGAFiD SL✓12 '' *lf�
[I GARI`l DI HI nI,NIn DIVISION nateReady/By: Mtn ES See Page 2for
Internet: www.tigard-or.gov - Notified/Method: se Supplemental Information
TYPE OF WORK EEF*$CIIEDULF
❑New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
VAddition/alteration/reptacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
pirI-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
0 Accessory building 0 Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: Catch basin or area drain 18.76
(it(06, S I .3 t-- Ave,
ty Ti3C9-f -- i 0�. ZZH Footing
drain
line,or trench drain 1 Page 2
City/State/ZIP: 7
Footing drain(no.linear ft.:� 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: .sW &A,(? �n ea, Manholes 18.76
/_
�f, 4 E ,S ® /Or e r..f/77 Rain drain connector 18.76
C 6f� -7- � /f77 1G- .Z-tc ELL/Ai e-- � Sanitary sewer(no.linear ft.: �j Page 2
U.a L/ a d&-x 'EZZ. - /vIp'"/ rr✓6-- /..;if__,
sewer(no.linear ft.:__) Page 2
r Water service(no.linear ft.: ) Page 2
Subdivision: /97VIv 7(f17d.d G>- (12--446/z tff°•: Fixture or item:
Tax map/parcel no.:Zatizet,/,r- f , '7/9! _"l l 1 q/7?%7/17)4; d Bacldlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
of`tlU y1_Q.t-L) ti i'sl.C..,_ M -t r r tote_ cfrowt. PLO vIA-e-- Dishwasher 25.02
`i. r?r CC I ( _C-f ro) .. 3 5� f4. llsra t� Drinking fountain 25.02
`l i A e K o p e- ,1 3c) 3!J iovC- . Ejectors/sump 25.02
tg PROPERTY OWNER I r„D TENANT Expansion tank 12.51
° ixture/sewer cap 25.02
Name:
fit; �(9-- \ LosJe�y v„eaor. Cu -cp"
Floor drain/floor sink/hub 25.02
Address: 1 4-1.t (,s Sc---) j 33 C .,t L. Garbage disposal 25.02
City/State/ZIP: Tq e 4 7.2,.-I el Hose bib 25.02
Phone:( ) J Fax:( ) Ice maker 12.51
❑ APPLICANT` .;❑ CONTACT PERSON Interceptor/grease nap 25.02
Medi2
Business name: 5 ia�J 4- Un (,t,.t d r5/`is /....i_.,, - / Prirne�! (value:S_) Pager 12.51
Contact name: lay fvlt 1'a+"5 i C Li '
f../ Roof drain(commercial) 12.51
Address: ( � SG3�se F Sink/basin/lavatory 25.02
City/State/ZIP: Pr•K i Alt: 9'7 ezep 6 Solar units(potable water) 62.54
Phone:(9,3)-7$73•-6,t 'Zit, Fax::(503) yZ9,j'- 1?1 Z. Tub/shower/shower pan 12.51
E-mail:,f(,l (fry! {� de.si"_ J u �'.' & (J i tc Lbl,,rl Urinal 25.02
h Water closet 25.02
CONTRACTOR Water heater 3752
Business name: Water Pp �i in WV 56.29
Address: Other: 25.02
€'� -#::
City/State/ZIP: /Kiln3 LeCe(e-5 000 t-1.-'(.. 12' Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50
C ii Lie.: 17 //e7 Plumbing Lie.no.: Q� J Z(fJ Plan review (25%of permit fee)
r State surcharge(12%of permit fee)
Authorized signature: hiel,re,6,_____.
t ftT 11 i IU1ALPERMIT FEE
Print name: 1'.-cJl,N f Date:1 0/ cif to This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
�Z-��7 /� ,` *Fee methodology set by'hi-Cormty Building Industry Service Board,
e-CP
ctsWa�i xtreraq rtaru-Peaawytaovlomyps�� i�J e444616-rpnrovconuwen) ,- V
RECEivE�
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUL 0 7 2020
_114
Reimbursement District Payment WorksI , FriG4RD
T I G A R I) 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov DIVISION
This worksheet must be completed by the Finance Department and provided
to the applicant to submit together with a completed plumbing permit
application and payment for sewer connection and reimbursement district fee,
if applicable, by expiration date shown below to the Building Division.
FINANCE DEPARTMENT TO COMPLETE:
Site Address: 14665 SW 133rd Avenue
OR
Reimbursement District #: none Parcel
#:Amount Due: $no fair share Amount Due Expires not part of a SRD
On:Applicant: Daytime
Phone:Email Address:
❑ Sewer Loan Processed (journal entry to follow for payment of deferred sewer
connection fce and reimbursement district fee, if applicable)*
By: Mai/Quack. Date: 7/6/2020
Name
Printed: Mai Quach
BUILDING DIVISION TO COMPLETE:
*Ifa sewer loan is processed, wait forjournal entry before creating plumbing and sewer permits.
Reimbursement Amount Paid: $ -- Receipt #:
SWR #: 3-6,,J,e02vr --coo cc, PLM #: / 2(/' aL1010—UUoZ�f�
Enter parcel conditions ' • cela (check all that apply):
Enter ".aid" condition.
❑ nter "deferral" condition, if applicable.
By:
Name
e Date: -7/ / )
Printed:
Attach this worksheet to issued sewer permit for records scanning.
1:1Building\Riembursement Districts\ReimDistPaymentWorksheet_NoDeferredAccounts_041918.docx