Permit CITY OF TIGARD PLUMBING PERMIT
1 ' COMMUNITY DEVELOPMENT Permit#: PLM2022-00201
Date Issued: 5/26/2022
Tr G A R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S111 DA22300
Jurisdiction: Tigard
Site address: 15429 SW APPLEWOOD LN
Project: Backflow Device Subdivision: HERITAGE CROSSING Lot: 42
Project Description: KOSTENKO new backflow for irrigation
Contractor: MANROOT LANDSCAPE AND IRRIGATION Owner: REYNOLDS, GALINA
100 CINDY LANE KOSTENKO,VALENTIN
DAYTON, OR 97114 15429 SW APPLEWOOD LN
TIGARD, OR 97224
PHONE: 971-237-6493 PHONE:
FAX:
FEES
Quantity Description Date Amount
I ea Backflow Preventer 05/26/2022 $31.27
Specifics: 1 12%State Surcharge- 05/26/2022 $8.70
Plumbing
Type of Use: SF
41 ea Minimum Fee Adjustment- 05/26/2022 $41.23
Class of Work: OTR Plumbing
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, 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 t 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: /)K/
Permittee Signature:
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.
•
Piumbin2 Permit Application
Site Utilities FOR OFFICE USE ONLY
City of Tigard R ea /�1 1
`'1 g I�1'. Date/B"y: �n/� Permit No.: {�L�xal� _,G1Gf
13125 SW Hall Blvd.,Tigard,OR 97223 vr/ G
= Phone: 503.718.2439 Fax: 503.598.1960 CITY Uh I e Other Permit No.:
TIGARD Inspection Line: 503.639.4175 p��)tLD�NG UthSb B : Juris.y See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
EXNew construction 0 Demolition For special information use checklist
Description I Qty. I Ea. Total
0 Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
rig 1-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
0 Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: j 54JQi S('i� Pip y i � Catch basin or area drain 18.76
DCity/State/ZIP: �1•'/* 6 09, 7 l-1�/��1-�t J`) Footing
drainleac(line,or trench drain Page 18.76
t`"�J "'` Q4 Footing (no.linear ft.: ) 2
Suite/bldg./apt.no.: Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
63 =(',/riCY
1\A A. Lc o p Rain drain connector 18.76
`-�� Sanitary sewer(no.linear ft.: ) 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
DESCRIPTION OF WORK Backwater valve 12.51
C `/\, Clothes washer 25.02
\Jl/l1c Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name:
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
Cl APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
J Medical gas(value:$_) Page 2
Business name: C. Ccp T _ G 1--
Primer 12.51
Contact name: Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
""" e Water heater 37.52
Business name: Man c alr t tail4 40ri Water piping/DWV 56.29
Address: kCO C, �/' ram- icp �r Other: 25.02
City/State/ZIP: \/ Of)... °,1 1 l` ' b J Subtotal
Phone:(Crj, ) a')-1-G 443 Fax:( `)) Minimum permit fee: $72.50
CCB Lie.: *�{), N Plumbing Lie.n .: Plan review (25%of permit fee)
aaJ! ///I�+ JlJ� State surcharge(12%of permit fee)
Authorized signature' C]"''�tl/r� J/, 111 /// TOTAL PERMIT FEE
Print name: t �,. pia ( ,� V 41- ,va i'2 I Date: 05/26/4) This permit application expires if a permit is not obtained within 180 days
r ��JJ 1 r `(JK�Z r after it has been accepted as complete.
v ��/�� *Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Penaits\PLMU-PennitApp.doc 10,01/09 440-4616T(10/02/COM/WEB)