Permit } ', PLUMBING PERMIT
r
a CITY OF TIGARD
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o COMMUNITY DEVELOPMENT Permit #: PLM2010 00092
+ s . 2 Date Issued: 03/30/2010
T[GAALY 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
,,, Parcel: 2S112CA02400
Jurisdiction: Tigard
Site address: 15220 SW GENTLE WOODS CT
Subdivision: GENTLE WOODS Lot: 16
Project: Shelly
Project Description: Installation of residential backflow preventer.
Owner: FEES
SHELLEY, MARY M Quantity Description Date Amount
15220 SW GENTLE WOODS CT
TIGARD, OR 97224 1 ea Backflow Preventer 03/30/2010 $31.27
PHONE: 503-684-9898 1 12% State Surcharge - 03/30/2010 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 03/30/2010 $41.23
Contractor: Plumbing
EXCELLENCE PLUMBING LLC
7520 SW 140TH AVE
BEAVERTON, OR 97008
PHONE: 503 - 643 -3459
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 Noti - ' • • enter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or di questions to • - C b :Ding 503.246.6699 or 1.800.332.2344.
1 .„,„,,, Is ued By: / � / /, Permittee Signat n
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.
Plumbing Permit Application
Site Utilities TOR OH I(.l. 1 4l ONLY:
City Of Tigard DaeteB 3 gp /0 / PermitNo.: 1 010/0 /O'C j L
� , ,, n 1312 SW HalI Blvd., Tigard, OR 97223
,, m Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Other Permit No.:
F " Inspection Line: 503.639.4175 Date By:
� T 1 C A R D`: Date Ready/By: �'/ El See Page 2 for
„�,, IV1 , ; Internet: www.tigard or.gov Notified/Method: r r� Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea 1 Total
l i s iit Addition/alteration/rep1a ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
Y CATEGORY OF CONSTRUCTION r) SFR (I) bath 312.70
g i- 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 ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOC ATION Site utilities:
Job site address: /5 22 S Vv t ?fl) ie /04i2/5 a Catch basin or area drain 18.76
/ / `9 �- t),C 6 ,72 Z Footing 1. leach line, or trench drain 18.76
City/State /ZIP:
�/ ! Footin 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
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.: Backftow preventer / 31.27 3/, 27
DESCRIPTION OF WORK Backwater valve 12.51
/ k jg ,i) p � Clothes washer 25.02
/ � � 1:41/ � j �
C Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
V PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: / f,'2/ 1 C/ //� _ _ / Fixture /sewer cap 25.02
/ 5 5k !✓'OJT /L� ASS C/ Garbage rb drain/floor eisa sink/hub 25.02
Address:
_ r/ Garbage disposal 25.02
City/State /ZIP: �/ t2, -t1 Di Hose bib 25.02
Phone: (Sam fob' 979 7 Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT - .P ERSON 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 12.51
E -mail: Urinal 25.02
Water closet 25.02
CONTRACTOR .
Water heater 37.52
Business name: e / f e ji (,o ' o �j ��� ( LLC Water piping/DWV 56.29
Address: "7526 Sk(/ / `/' Other: 25.02
City/State /ZIP: ' ea1 /ede", Subtotal . 3 ) 27
/ Minimum permit fee: $72.50
Phone: �� ) ( 3 -' _05 9 Fax: ( ) C/
CCB Lic.: / 75 7, 1 tOpf t Plumbing Lic. no.: P,B3 / Plan review (25° of permit f ee)
/� ?/ / r ( State surcharge (12 /0 of permit fee) t, AD
signature: l 7 TOTAL PERMIT FEE el. Ao
� `_ Thi permit application expires if a permit is not obtained within 180 days
N
Print name: Y6e // p en / Q Date 3 -2q - /D
// J after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.