Permit CITY OF TIGARD PLUMBING PERMIT
• Permit#: PLM2021-00372
COMMUNITY DEVELOPMENT
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 9/2/2021
Parcel: 1 S 134C D03600
Jurisdiction: Tigard
Site address: 11950 SW KATHERINE ST
Project: Baccellieri Subdivision: LERON HEIGHTS NO.3 Lot: 63
Project Description: Moving piping for kitchen and laundry room sinks.
Contractor: OWNER Owner: BACCELLIERI, FRANCES D TRUST
11950 SW KATHERINE ST
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Sink 09/01/2021 $25.02
Specifics: 1 ea Laundry Tray 09/01/2021 $25.02
1 12%State Surcharge- 09/01/2021 $8.70
Type of Use: SF Plumbing
Class of Work: ALT 22 ea Minimum Fee Adjustment- 09/01/2021 $22.46
Type of Const: Plumbing
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: Permittee Signature: C' ` /pzy1
X "/l//X/ ` /`
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Applicatio4ECEIVEC
Building Fixtures lr tt/lit Ui 1 1( I I .1 (1\1 1
City of Tigard AUG 2 6 2021 Receivedl T / Z/ 4 1a PnmitNoP[,$'1 Zry.Ze_D/1/�
:� " 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review// `C v!R r.-
g Phone: 503.718.2439 Fax: 503.598.1�TY OF TIGAR[) Other Permit No.:
Inspection Line: 503.639.4175 r � Date/By:By.
1-I(;:1t:1) Internet: wwlv.ti and-or. ov BUILDING UIVISfVry Date Readythod: //z./ �l a Jurist la Sre Page t for
g g Notifcd'Method: (! Supplemental Information
TYPE OF WORK f 1?-/L / i iV',E.-/ FEE* SCHEDULE
❑New construction ❑Demolition For special Information use checklist,
Description j Qty. I Ea. I Total
li'Addition/a1teration!replaccment ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
Uf<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
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: t I �4, silo, K,a.+A..e-fr v e Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP: 9 7 , .a-'3
1 t 4 • dF P Footing drain(no.linear 0.:_) Page 2
Suite/bldg./apt.no.: LI I Project name: b „einP i I i p`r`i Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
1 1 l,}� Rain drain connector 18.76
(� Sanitary sewer(no.linear fl.:_) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
ik'i,t r o t e` Q i YL ',f 1/ jc 1 I pis.�_3 Dishwasher 25.02
4-- i LG�4.4-'A. X-C ro p-744 -$.3 Ktc. Drinking fountain 25.02
Ejectors/sump 25.02
&PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: F Q.. i'C_ / �Ke j) SL t ,e w e l (i eri• Fixture/sewer fIo r 25.02
V e k_1�-�-�- Floordrain/floorsink/hub 25.02
Address: �
i '/1 5-2D �v..). :��/K e__ Garbage disposal 25.02
City/State/ZIP: --1-� �� V J` q 7a_?.a_?.� h/' Hose bib 25.02
Phone:( �.�_(/_ 4_ g'� Fax:( ) Ice maker 12.51
[.,APPLICANT [.CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ I Page 2
Contact name: J r Primer 12.51
�fis �.+ +d ye. , Roof drain(commercial) 12.51
Address: Sink/basin/lavatory K 25.02 67),04-
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( 1 Tub/shower/shower pan 12.51
7 /� Urinal 25.02
E-mail: y 11k--t laC_ .t It. L� Wm�a. . C-25.M
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal 1)4-
Phone:( ) Fax:( ) Minimum permit fee: $72.50 7Z, 5 O
Plan review (25%of permit fee)
CCB Li c.: Plumbny Lic.no.:
s State surcharge(12%of permit fee)
P"':'a
Authorized signatu`itr- � -- ���� TOTAL PERMIT FEE p/, y6
Print name: `JIr/// , / • Date: /' This permit application expires if a permit is not obtained within 180 days
�i4-fVt t't� i 1 �! �lt�/G ma.t after 11 has been accepted as complete.
•Fee methodology set by TO-County Building Industry Service Board,
t."BaitdtoaTernats,PLMIJ-I•ermitApp_dnc IO.b U09 440-46162110,02'COMNIEBl
RECEIVED
Property Owner Statement AUG 2 F; 2011
Regarding Construction Responsibilities CITY OFTIGARD
Oregon Law requires residential construction permit applicants who are not IicensedwJj DIVISION
Construction Contractors Board to sign the following statement before a building permit can be
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.
•
#11,1,16fS Aiu'rlfil:rr7
Print Name of Permit Applicant
C (/3,/,/
Signature of Permi li Date
Permit#: 1" L-M 74.) 2'_069 7;,z--
11956 .czd I-R'TH-C-li./� y <
s>
Address: r,47&174
/ \11.41:-14141111/77'
Issu
ed by: ile Date: �lo?(oZ
This Copy for Permit Offices