Permit CITY OF TIGARD PLUMBING PERMIT
1,11
�. COMMUNITY DEVELOPMENT Permit#: PLM2021-00232
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 6/8/2021
Parcel: 1 S 134CB 17200
Jurisdiction: Tigard
Site address: 12340 SW ANTON DR
Project: Hancock Subdivision: ANTON PARK NO.2 Lot: 99
Project Description: Replace double check valve
Contractor: OWNER Owner: HANCOCK, RALPH SCOTT
12340 SW ANTON DR
TIGARD, OR 97223
PHONE PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 06/03/2021 $31.27
Specifics: 1 12%State Surcharge- 06/03/2021 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment- 06/03/2021 $41.23
Plumbing
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, Stale 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: }{oily VcuvDe4LUege Permittee Signature: Ovt,,4ppltcatwn
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 ApplicaaECEIVED E S/2:i/2-j
Building Fixtures Awe; r >p f
City of Tigard Received at 03102! PermitNo.{7(f l�/�.0 IJV 2...„• 13125 SW Hall Blvd.,Tigard,OR 9?iz Y OF TIGARD Plan Review / y-
g Phone: 503.7182439 Fax: 503 .�-%M.I/� DIVISION ma y' N/"r �rPermsNo.:
II Internet
Inspection Line: 503.639.4175 U V V 1�ReadyBy: _I emu: ® see Page 2 far
gird-or.gov Notified/Mcelwd �� 1 i srypk....to wo,uNloa
• TYPE OF WORK FEE" SCHISMS
❑New construction ❑Demolition For special information Mae checklist
1
New 1- -
g Additionlalteration/replacement 0 OtherDescription I Q1y. E Total
famUy dwellngs(includes 100 ft.for each utility connection)
CATEGORY.01f.1 CONSfRUCDON SFR(I)bath 312.70
{41-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
-
❑Accessory building 0 Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder 0 Other Fire sprinkler( ,sq.ft.) Page 2
FOR.SITE INFORMATION AND LOCATION • Site Mintier
Job site address: / E,.3!/t) S W A Ny7-Dq.J7 D Catch basin or area drain 18.76
Dry6
City/State/ZIP: 7'/�4-LD r tie, r�s ( ! Z 33 "rag leach line,liornear
trench drain Page18. 2
Footing drain(no.linear ft.: ) 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross streeVdirections to job site: Manholes 18.76
1./ hl pal D 6 kotn Rain drain connector 18.76
Sanitary sewer(no.linear ft.: _ ) Page 2
Storm sewer(no.linear R.: ) Page 2
Subdivision Water service(no.liner ft.:_) Page 2
Lot no.: Fixture or item: y
Tax map/pareel no.: Backtlow preventer 31.27 3�,4 7
DESCRIPTION OF WORK Backwater valve 12.51
- - Clothes washer 25.02
j n_A ca- E)C I ST7 N� pPr, .bk C. H_ Dishwasher 25.02
VA`I___ Drinking fountain 25.02
Ejectors/sump 25.02
' jg PROPERTY OYT4ER 0 TENANT Expansion tank 12.51
Name: ✓q g�) �/4-�coC� Fixture/sewer cap 25.02
Address: / .3 Y 'a SW A N'�0►`S D) GarbFloo drain/flooriap sinlubub J 25.02
CitylState(ZIP:'f q Garbage disposal 25.02
/�v�Lit> 04, / ZZ-3 Hose bib 25.02
Phone:(Soy 5 y y... 4;b q 6 Fax:( ) Ice maker 12.51
P.APPS.ICANT PCONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:S_) _ Page 2
Contact name: h 4 iz A aj H vC� Primer 12.51
Address: , A -. 'n Roof drain(commercial) 12.51
/�- i/v k,! /T1J-r 7� Sink/basin/lavatory 25.02
City/State/ZIP:fl j >i i1_ C7 7 Z -3 Solar units(potable water) 62.54
Phone:(S 3) c-jt/-51,116 Fax::( ) rub/shower/$wwcr pan 12.51
E-mail:LI7AR .�.1 c)Be c 6n i -bi-. afri
Water
25.02
t� CONTRA ater closet 25.02
Water heater 37.52
Busine
Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal 31. Z. 7
Phone:( Fax:( )
Minimum pemrit fee: 572.50
'l Plan review (25%of permit fee)
CCB Lie.: P mbing Li o.: -
State surchargeTO(1TAL2%PERMI of permTit fee FEE)
Authorizedxed signature: ..- 2js2
Print name: K 4 la HAr,+L Date: r)--L j..s r TYb permit applfeatba expires If a permit Is sot olaalaed within 188 days
e-f after It has bees accepted as eoeapkle.
*Fee methodology act by Tri-County Building Industry Service Board.
ttatiidoarPormartetmU-PamaArs.dec 10101109 440A61FTt I ttnV'COµWEal
Property Owner Statement RECEIVED
Regarding Construction Responsibilities MA{ '7 2021
Oregon Law requires residential construction permit applicants who are not licensed with OF TIGARD
Construction Contractors Board to sign the following statement before a building permit9,,b1G DIVISION
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical,and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement.This statement will be filed with the permit.
Please check the appropriate box:
{----
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
Print Name of Permit Applican�j'%/�
/Thy 25 Z°Zj
Si ature of Permit Applicant Date
Permit#: .�
Address:
issued by: Date: ---_.._ 113
This Copy for Permit offices