Permit IN ' "` CITY TIGARD PLUMBING PERMIT
a ., COMMUNITY DEVELOPMENT Permit #: PLM2009-00350
T i GAR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 12/15/2009
Parcel: 2S 104AA02400
Jurisdiction: Tigard
Site address: 12265 SW 127TH AVE
Subdivision: BELLWOOD Lot: 73
Project: Wyffels
Project Description: Replace up to 100' water service.
Owner: FEES
WYFFELS, HENRY R Quantity Description Date Amount
12265 SW 127TH AVE
TIGARD, OR 97223 100 If Water Service 12/15/2009 $62.54
1 12% State Surcharge - 12/15/2009 $8.70
PHONE: Plumbing
10 ea Minimum Fee Adjustment - 12/15/2009 $9.96
Contractor: Plumbing
RAYBORN'S PLUMBING INC
19990 SW CIPOLE RD
TUALATIN, OR 97062
PHONE: 503 - 692 -4139
FAX: 503 - 691 -2328
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: �`
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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.
• ''= ';�0.� 694 2328 Rayborns Plumbing RECEIVED 03:01:40 p.m. 12 -14 -2009 1 /2.
Plumbing Permit Application DEC 1 4 21''.
Building Fixtures .
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1- City of Tigard CITY OF TIG 'x ed
_ , Permit No. ' t.- •4) .A, •
011 e 13125 SW Hall Blvd., Tigard, OR 97 ANNI(� = "' a -
tip iJ
;12 . Phone: 503.639.4171 Fax: 503.598.1960
Date/B Other Permit No.:
7: Inspection Line: 503,639,4175
I - ItlQl - Date Ready/By: 0 See P e 2 for
Internet: www.tigard- or.gov Notified/Method: (� Sapple m entallaformatioo
TYPE OF WORK FEE* SCHEDULE
❑ New construction Foy
❑ Demolitio special information use checklist.
Description 1 Qty. I Ea. ( Total
Addition /alteration/replacement ❑ Other: New 1 - 2- family dwellings (includes 100 It. for each utility connection)
and 2-family CATEGORY OF CONSTRUCTION SFR (I) bath _ 312.70
1 - dwelling SFR (2) bath
Y g ❑ Commercial /industrial 437.78
❑ Accessory building ❑ Multi- family SFR (3) bath 500.32
❑ Master builder Each additional bath/kitchen 25.02
❑ Other: Fire sprinkler ( sq. ft.) Page 2
/ /�?� S S ,✓ 4 JOB SITE INFORMATION AND LOCATION Site utilities:
,ii
/ Job site address: L-- ,4ae
Catch basin or area drain 1 8.76
pu(� Drywall, leach line, or trench drain 18.76
City / State/ZIP: 773 av -( q `� Q, '�(
v fLC�/ G'` Footing drain (no. linear ft.: _ ) Page 2
Suite/bldg. /apt. no.: Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
i
Sanitary sewer (no. linear ft.: ` ) Page 2
Storm sewer (no. linear ft.: _ ) Page 2
Water service (no. linear ft.: 6D) CO Page 2
Subdivision: Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 3I.i
DESCRIPTION OF WORK Backwater valve 12.51
/�� ' t !w ie /f/ Clothes washer 25.02
/� _..)' f ti' Cr Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
, f ` PROPERTY OWNER ❑ TENANT Expansion tank 12.51
I Name: 1 .0 y rCi-, Fixture/sewercap 25.02 ,
Address:
Floor drain /floor sink/hub 25.02
Garbage disposal • 25.02
City/State /ZIP: Hose bib
25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: �, 1 b r to S f /� t� i vi Medical gas (value: S � ) Page 2
'/ H
Contact name: 4/ ,e_ yun, /rte l Primer 12.51
Roof drain (commercial) 12.51
Address: / 99 ' St ✓ C, po I Q Sink/basin/lavatory 25.02
City/State /ZIP:"7jG \nlA ;� Or q Solar units (potable water) 62.54
Phone: () 6 -6 1a _ ` eI F ax : : (yo3 ) 6Gt 1 - ,D 3 Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
ie , /' . , r , a tom
CONTRACTOR
Water closet 25.02
P \ _ Water heate 37.52
Business name: R b� f 0 r S `V tM,�o i v�
k, \A-C.- Water piping /DWV 56.29
Address: + CkQ S„,,.) l / 1 ,a 0 S„� f 4_ ' R Other: 25.02
esti
City/State/ZIP: l'u f�.ra 1. •, w O Y . Q:t' _ �
�`� � Subtotal
Phone: (Spy ) 6 C1a- l c� Fax: (Sp� de f a31g Minimum permit fee: S72.50
/ 9s 4 `�\ Plumbing Lic no.: 39 - 1 6 6 P4 Plan review (25% of permit fee)
CCB Lic.: q
State surcharge (12% of permit fee) �
Authorized signature: 7/1 ij I TOTAL PERMIT FEE • "
Print name: NG! ht� N u Date: ! I L/ _ �J This p ermit application expires if a permit is not obtained within 180 days
/ i after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board
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