Permit
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2010-00030
13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 01/2212010
Parcel: 2S103BD05000
Jurisdiction: Tigard
Site address: 12555 SW 116TH AVE
Subdivision: HUNTER'S GLEN Lot: 6
Project: Shimojima
Project Description: Replace shower.
Owner: FEES
SHIMOJIMA, KOREY Quantity Description Date Amount
12555 SW 116TH
TIGARD, OR 97223 1 ea Tub/Shower/Shower Pan 01/22/2010 $12.51
PHONE: 1 12% State Surcharge - 01/22/2010 $8.70
Plumbing
60 ea Minimum Fee Adjustment - 01/22/2010 $59.99
Contractor: Plumbing
MODERN PLUMBING
11120 SW INDUSTRIAL WAY
TUALATIN, OR 97062
PHONE: 503-691-6166
FAX:
Type of Use: SF
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, 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 952-001-0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Jan. 22. 2010 2:44PM Modern Plumbing No. 8247 P. 2
. .
P'ildmbing Permit ApplicatioriECEIVED
Building Fixtures g FOR 011:10.'. IISF. ONLY
City of Tigard JAN 2.2 2010 Received
Permit No.; �. rn • 0, i i0 0
:4 i Plan Review • 13125 SW Hall Blvd., Tigard, OR 97223 "
Phone: 503.639.4171 Fax: 503.598 OF TIGARD DateBy: Other Permit No.:
l ' I (-: A k 1 ) Inspection Line: 503.639.4175 De ReadylBy: d HI See Page 2 for
Internet: www.tigard ar.gov BUILDING DIVISION Noti fed/Method: � _
Supplemental Information
TYPE OF WORK . PEE" SC EDULE
•
❑ New construction 0 Demolition For special Information use checklist
Description I Qty. I Ea I Total
' Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION . SFR (1) bath 312.70 -
WI- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen _ 25.02
❑ Master builder CI Other: Fire sprinkler ( sq. R) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 1 . 5 S 5 6 LA.) / �'ti+ a.-4.1-(9 Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City/State/ZIP:
t . r ej r O -7' Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. w.: Project name: �ii 4r)3) t'1'ti0. Manufactured home utilities 50.03
Crass slreet/directions job site: / Manholes 18.76
B / �,I� U I.A.�C l / O .S c rz_V Rain drain connector 18.76
1) F� ./,‘ 44 u 3 Sanitary sewer (no. linear ft.: 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 �acliwaur I2.!l
�� Clothes washer 25.02
- �j�^•- �,r4 -S -� � Dishwasher 25.02
a Drinking fountain • 25.02
• Ejectors /sump 25.02
❑ PROPERTY OWNER I . ` TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.
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
. • ❑ APPLICANT ' a CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ , ) Page 2
• 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 I 12.51 I), s )
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
• / Water heater 37.52
�
Business name. / r og f ien �f tJ✓ 1- G Water piping/DWV 56.29
Address: // / )- c 5b-,) f 'US 21 ‘ ,0 6- LLieLy Other; 25.02
City/State/ZIP: Tv ( ,„,, I O Y�.- 7 0 6 1 Subtotal
Phone: (503) ( I to (!a b Fax: (51D3) 01 -6,11 / Minimum permit fee: $72.50 '. SD
_ CCB Lie.: O r I to i, Plumbing Lic, no.:.3 asa Plan review (25 %ofpermit fee)
State surcharge (12% of permit fee) : 70
Authorized Printname si signature: / � / Q{�-1 illt(.C- / TOTAL PERMIT FEE MO
o (C-/ y /7 0.� 1e - Date; / -4).) This permit application e if a permit is not obtained within 180 days
! e U u 2
after It t has has b been accepted as complete.
- fee methodology set by Tri County Building Industry Service Board.
1:\Bwldineermi ePL.tU- PermitApp.doo 10101/09 44o- 4616T(I0 /ovCOwwEa)