Permit „ CITY OF TIGARD PLUMBING PERMIT
`' 1111
COMMUNITY DEVELOPMENT Permit#: PLM2021-00460
Date Issued: 11/4/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S102BB00404
Jurisdiction: Tigard
Site address: 12045 SW KAROL CT
Project: Johnson Subdivision: KAROL COURT Lot: 3
Project Description: Relocating kitchen sink.
Contractor: OWNER Owner: JOHNSON, CLIFFORD A&CYNTHIA LEE
12045 SW KAROL CT
TIGARD,OR 97223
PHONE: PHONE.
FAX:
FEES
Quantity Description Date Amount
1 ea Sink 11/03/2021 $25.02
Specifics: 1 12%State Surcharge- 11/03/2021 $8.70
Plumbing
Type of Use: SF 47 ea Minimum Fee Adjustment- 11/03/2021 $47.48
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
I
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:
No-(,l,y Va-w,De-Wege Or,,,A vL.
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 AppliciaEli C E I ` E D E
Building Fixtures OCT 2 6 2021
miz Ulric , I sl' ONr.,
City of Tigard CITY OF TIGARD Received 1 w 13125 SW Hall Blvd.,Tigard,OR 97 3 Date/By: /-- t.1 Permit No.: Q` ^�,/ /ZV 1 a)
i Phone: 503.718.2439 Fax: 503 NG DIVISION Plan ReviewIN
No.: ) I�`r VL
Inspection Line: 503.639.4175 Date Re �f(� Other Permit No.:�r i I y 1, G�>:v
T 1 ft A R DDate ReadyBy: lens: See Page 2 for
�/a�/ :r!
Internet: www.tigard-or.gov / /f j
Notified/Method: F,/3 i i -n Supplemental Information
TYPE OF WORK / FEE* SCHEDULE
❑New construction ❑Demolition Fur,s ecial in ormitfion use checklist
SI Addition/alteration/replacement 0 Other: Description r Qty. 1 Ea. Total
%iti
New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
I-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
N.N Accessory building
SFR(3)bath
y g 0 Multi-family 500.32
❑Master builder - Each additional bath/kitchen 25.02
0Other: Fire sprinkler( sq.ft,
<* JOB SITE INFORMATION AND LOCATION ) Page 2
Site utilities: --
k Job site address: i 2 C LIS 3 kl (y,,aro/ C Catch basin or area drain 18.76
Ai_City/State/ZIP: 1♦♦!��� Y l JY (' Drywell,leach line,or trench drain 18.76
7 ..)-
uite/bldg./apt.no.: Project name: y Footing drain(no.linear ft.: ) Page 2
t.,4 f(,1-e'f. R P,ni G i A f Manufactured home utilities 50.03
peross street/directions to job site: "j Manholes
18.76•
• . T „„) ^, '_ 6,1 ,f-L 1 Rain drain connector 18.76
/ -` C.,
Sanitary sewer(no.linear ft.: ) Page 2
VStorm sewer(no.linear ft.: ) Page 2
Subdivision: Water service(no.linear ft.: ) Page 2
Lot no.: Fixture or item:
Tax map/parcel no.: Back-flow preventer 31.27
f DESCRIPTION OF WORK Backwater valve
Clothes washer 12.51
il q Lr 1 t C., C I J r = _ 25.02
( Dishwasher
25.02
Drinking fountain 25.02
7 _ Ejectors/sump 25.02
I PROPERTY OWNER 0 TENANT Expansion tank
y `,, ' (� 12
...51
.h C_.J Name: i I f-xy t1 Jt,iI tL`5(9 Fixture/sewer cap 25.02
�►Address: /zu t i ar $ (t" 1 F� " �`,I C L Floor drain floor sink/hub 25.02
City/State/ZIP: '� ft ZLC 4t Garbage disposal 25.02
VVV t' reE �i" 1).22 3 Hose bib 25.02
931 Phone:(.�)3).11, -57 C
t•S Fax:( ) Ice maker
, ❑'APPLICANT 12.51
❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name:
Medical gas(value:$
) Page 2
Contact name: Primer 12.51
- Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory
City/State/ZIP: 25.02 ��
Solar units(potable water) 62.54
Phone:( ) I Fax::( ) Tub/shower/shower pan
----- 12.51
E-mail: lJr nal
25.02
CONTRACTOR Water closet 25.02
Business name: � .� Water heater 37.52
Water piping/DWV 56.29
Address:
Other: 25.02
City/State/ZIP:
_ Subtotal c- a
Phone:( ) Fax:( ) Minimumpermit fee: $72.50 l 7 t�li
CCII Lie.: �� ; Plumbing L.ic.no.: Plan review (25%of permit fee)
Authorized signature: �/> State surcharge(12%of permit fee) Jr..7Cb
Print e: (/1'1 1 '" J U `_ TOTAL PERMIT FEE? p
""r"1 F.+i'7. . 70Im:S�7� Date:/rig7,20. This permit application expires if a permit is not obtained wit n 18days
0 i
v 'i!_ after It has been accepted as complete.
eFee methodology set by Tri-County Building Industry Service Board.
r/Botdmg•,Permos/PLMII-PeemitApp.doc 10/01/09 440-4616T(10/02,COhL'WEB)
RECEIVED
Property Owner Statement oCT 2 s 2021
Regarding Construction Responsibilities L;iTY of TIGARU
Oregon Law requires residential construction permit applicants who are not licensed with theU'LDENG 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.
Fc,re/ Vt�4 n t r'..
Print Name of Permit Ap ' ant
Signat r of Per Applicant
Date
Permit#:
Address: �i +ue-
Issued by: Date: 6
This Copy for Permit Offices