Permit , . , CITY OF TIGAR® PLUMBING PERMIT
' '>z , Q COMMUNITY DEVELOPMENT Permit #: PLM2010 -00115
?^ Date Issued: 04/16/2010
rTIGf,RD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S102AD01300
Jurisdiction: Tigard
Site address: 9105 SW BURNHAM ST
Subdivision: Lot: 0
Project: Burnham Street Improvements
Project Description: Relocate irrigation backflow device.
Owner: FEES
Quantity Description Date Amount
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
Contractor: Plumbing
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: /e ced
Permittee Signature:
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Cali 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 ApplicationRECEIO N .,` /F it
Building Fixtures V FOR OFFICE USE ONLY
City of Tigard APR 15 2010 Date/By: % /4 0 / 0 di r it No P / -- 00/ 45
11 13125 SW Hall Blvd., Tigard, OR 97223 rrd� plan Review
C Phone: 503.639.4171 Fax: 503.598.19itOTY OF TIGAR DateBy: Other Permit No.:
TIGARD Inspection Line: 503.639.4175 BUILDING DIVISION Date Ready/By:
IV' ® See Page 2 for
Internet: www.tigard- or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. [ Ea. 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
❑ 1- 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 LOCATION Site utilities:
, Catch basin or area drain 18.76
+. J 3v r' -.
Job site address: 910 6 5 „, ,, Ir ..„
Drywell, leach line, or trench drain 18.76
City/State /ZIP: 1 jet; eZ ,d O R.. / A 722 3 Footing drain (no. linear ft.: , ) Page 2
Suite/bldg. /apt. no.: I Project name: 3 u rn ReWl t 7 ryt ft iitV'rnes pe,. Manufactured home utilities 50.03
Cross street/directions to job site: / Manholes 18.76
Ram dram 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
Clothes washer 25.02
f
ReI oc _TrrI J efii ,, , b dcviec' b f e h'..,u f Dishwasher 25.02
At t s 4 e poem: Drinking fountain 25.02
Ejectors /sump ,126ROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Fixture /sewer cap 25.02
Name: 4 - j -t / Floor drain/floor sink/hub 25.02
Address: 9/05- :5 , � ,,,t, /1„ ,, Garbage disposal 25.02
City/State /ZIP: TT) z,, Op_ 97223 Hose bib 25.02
Phone: ( ) f Fax: ( ) lce maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Business name: 12.51
Primer
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: 25.02
Water closet
CONTRACTOR Water heater 37.52
Business name: / D' 4 K 74 , H't Cc', 7 (p,, Water piping/DWV 56.29
Address: 0 K 6 j - Other: 25.02
City/State /ZIP: --17 A V A rt t./, 0 Z. 9 7 0 (D 2.- Subtotal
�1
Q Minimum permit fee: $72.50 /a .50
Phone: (503) ? 3 - 4 - DI
Q Fax: (S) (0 U +'l 1
p Plan review (25% of permit fee)
5
CCB Lic.: 5 z e Plumbing Lic. no.: 34- 4 1 r State surcharge (12% of permit fee) $. 7
Authorized signature: TOTAL PERMIT FEE "1 , d'
Print name: FAA A n /� 1,..„) o j Otj Date: /' /10 ✓
This permit application expires if a permit is not obtained within 180 days /
after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
:\ Building \Permits\PLMU- PermitApp.doc 10/01/09 440-4616T(10 /02/COM/WEB)