Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2010 -00118
Date Issued: 04/16/2010
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S102AD02400
Jurisdiction: Tigard
Site address: 8950 SW BURNHAM ST 100
Subdivision: BURNHAM TRACTS Lot: 5
Project: Burnham Street Improvements
Project Description: Relocate irrigation backflow device.
Owner: FEES
NW PREFERRED FEDERAL CREDIT UNIO Quantity Description Date Amount
8450 SW BURNHAM, PO BOX 231269
TIGARD, OR 97281 1 ea Backflow Preventer 04/16/2010 $31.27
PHONE: 1 12% State Surcharge - 04/16/2010 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 04/16/2010 $41.23
Plumbing
Contractor:
KODIAK PACIFIC CONSTRUCTION
PO BOX 886
TUALATIN, OR 97062 -0886
PHONE: 503 - 783 -4300
FAX: 503 - 682 -3777
Type of Use: COM
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.
Plumbing Permit Applicati
Building Fixtures RECE FOR OFFICE USE ONLI
.
City of Tigard Date/By: 9 4/40 io
/X-- No.: - ncr7 //P
13125 SW Hall Blvd., Tigard, OR 9722 QP 15 2010 Plan Review
C Phone: 503.639.4171 Fax: 503.59 Date/By: Other Permit No.:
Inspection Line: 503.639.4175 �ll 0 Y OF TIGARO) Date Ready/By: Juris: 10 See Page 2 for
I I (J A It D Internet: www.tigard - or.gov BUILDING rnVIsloi ` Notified/Method: ' , Supplemental Information
TYPE OF WORK FEE* SCHEDULE
For special information use checklist
❑ New construction ❑ Demolition Description I Qty. I Ea. 1 Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2-family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
SFR (2) bath 437.78
❑ I- and 2- family dwelling ❑ Commercial/industrial -
SFR (3) bath 500.32
❑ Accessory building 0 Multi - family Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler (_ sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: g 9.5 5 c� (..) • y i.,,.1 i• Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City /State /ZIP: j ct, / o 9-, 9 722 3 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Project name: 3 u rp Ae yvt $t, rer ' 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: I Lot no.: Fixture or item:
Backflow preventer / 31.27
Tax map /parcel no.:
Backwater valve 12.51
DESCRIPTION OF WORK 25.02
�j 1 J Clothes washer
I'�t'OC .-- rit"15e bat idlo 1 CAc vi4 r i„2, A "''Q Dishwasher 25.02
alt t.du Sl`e,1P W el Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I TENANT Expansion tank 12.51
Fixture /sewer cap 25.02
Name: C/`1' d°vA -,...,-% { Floor drain/floor sink/hub 25.02
Address: i'395 '1.5'.A , mss, Li. Y1 fR� 2+ Garbage disposal 25.02
City/State /ZIP: T7 , o fz, 972 23 Hose bib 25.02
Phone: ( ) J Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Business name:
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
Urinal 25.02
E -mail:
Water closet 25.02
CONTRACTOR Water heater 37.52
Business name: ko p/4 K 17/4-c t.F/t CQA/,,7 '( p Water piping/DWV 56.29
Address: j p o 3,K a% Other: I 25.02
City/State /ZIP: `7„tAL41z tJ 0 Z. 97 0 le 2. Subtotal
Minimum permit fee: $72.50 7A -
Phone: (SOS) - 7 o 3 - 434 0 Fax: (s ,$) too U , p ` ?" 7 7 , o
Plan review (25% of permit fee)
CCB Lic.: 5 j �} ..3 Plumbing Lic. no.: 34 - 41 / ? State surcharge (12% of permit fee) $. 11
Authorized signature: TOTAL PERMIT FEE Ti. 9.0
This permit application expires if a permit is not obtained within 180 days
Print name: p fj J 4 1 f �S Date: + / J Q after it has been accepted as complete.
f *Fee methodology set by Tri-County Building Industry Service Board.
I:I Building \Permits\PLMU- PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB)