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CITY OF TIGARD PLUMBING PERMIT
11111 r COMMUNITY DEVELOPMENT Permit#: PLM2021-00446
Date Issued: 10/28/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 2S 111 AD04700
Jurisdiction: Tigard
Site address: 8990 SW PINEBROOK ST
Project: Hoogendam Residence Subdivision: PINEBROOK TERRACE Lot: 70
Project Description: Plumbing re-pipe for new cabinets,
Contractor: OWNER Owner: HOOGENDAM, SHANE M&LISA M
8990 SW PINE BROOK ST
TIGARD, OR 97224
PHONE PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Dishwasher 10/28/2021 $25.02
Specifics: 1 ea Garbage Disposal 10/28/2021 $25.02
1 ea Lavatories 10/28/2021 $25.02
Type of Use: SF 1 12%State Surcharge- 10/28/2021 $9.01
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $84.07
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: Ho-LLy Va.w De,1/ cgZ Permittee Signature: Qw Apr-Lizo4-i-o-vu
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.
. RECEIVED
Plumbing Permit Application
Building Fixtures OCT 2 7 LO21 FOR OFFICE ( SF (l\I.l
City of Tigard CITY OF TIGAFfLj Rcccivcd 1012Z421 PiIn �- Le
lig Uatc Ay: Permit No.
'i 13125 SW hall Blvd.,Tigard.OR BUILDING DIVISION'
■ Phone: 503.718.2439 Fax: 503.598.1960 Plan By. Other Permit No..
Date By.
Inspection Line: 503.639.4I75 Date Read B
1 1 i4 N.I) Internet: www.ti Bard-or. ov Ready:By: /rx 1 n' m tau, I Supplemental Sec Page 2 Ifnformation
TYPE OF WORK t1iVi A FEE* SCHEDULE
❑New constructionFor s vial in ornmrion use checklist.
0 Demolition
Description Qty. I Ea. 1 Total
XAdditionJalteration/replacement ❑Other: New 1-2-family dwellings(includes 10011 for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
X 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78�
SFR(3)bath 500.32
0 Accessory building ❑Multi-family
--- 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: 8990 SW Pinbebrook Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP: Tigard, OR 97224
Footing drain(no.linear ft.:_) Page 2
Suite/bidgJapt.no.: Project name: Hoogendam Kitchen
g Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
SW Pinebrook and SW 92nd Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
-- - Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear II.:_) Page 2
Subdivision: Lot no.: Fixture or item: -
Tax map/parcel no.: BackOow preventer 31.27 .
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Plumbing re-pipe for new cabients _ _ _ Dishwasher 1 25.02
_ Drinking fountain 25.02
Ejectors/sump 25.02
31 PROPERTY OWNER 0 TENANT Expansion tank 12.51
Name: Shane Hoogendam - Fixture sewer cap 25.02
Floor drain floor sink huh 25.02
Address: 8990 SW Pinbebrook _ Garbage disposal 1 25.02
City/State/ZIP: Tigard, OR 97224 __ _ _ Hose bib 25.02
Phone:(503) 757-3412_ _ I Fax:( -) lee maker 12.51_
❑ APPLICANT 'CONTACT PERSON Interceptor/grease trap 25.02
Business name: RA Gray Construction Medical gas(value:S_) Page 2
AJ Michaud Primer I2.51
Contact name: -
- Roof drain(commercial) 12.51
Address: PO Box 1000 - Sink/basinllavatory 1 25.02
CityiState/ZIP: Sherwood, OR 97140 Solar units(potable water) 62.54
Phone:(503) 692-4675 I Fax::( ) Tub/shower'shower pan 12.51
E-mail: ajmichaud@ragrayconst.com Urinal 25.02
Water closet 25.02
F CONTRACTOR
Water heater 37.52
Business name: Work by owner Water piping'DWV 56.29
Address: Other: 25.02
City:State//Z1P: Subtotal
Phone:( ) Fax:( ) Minimum permit tee: 572.50
Plan review (25%of permit fee)
CCB Lie.: Plumbing Lic.no.:
State surcharge(12%of permit fee)
Authorised sigma --
- _ TOTA1_PERMIT TEE
Print name: Shane Hoogendam Date: 10-26-21 This permit application expires if a permit is not obtained within Ito days
after it has been accepted as complete. )'
'Fee nxthodulotr set by Tre-County Building Industry Service Board
I Budding Permits'.PLML'-PennitApp.doc 101)109 430.4616Tt In+02:COvvWmaI
t
RECEIVED
OCT
Property Owner Statement
CITYY7 2021
OF TIGARU
Regarding Construction Responsibilities BUILDING DIVISION
Oregon Law requires residential construction permit applicants who are not licensed with the
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
XI 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.
Shane Hoogendam
Print Name of Permit Applicant
10-26-2021
Signature of Permit Applicant Date
Permit#:
Address:
\
Issued by: __. Date:
This Copy for Permit Offices