Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009-00326
T I GAR 1) 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/05!2009
Parcel: 2S112CD07300
Jurisdiction: Tigard
Site address: 15838 SW 76TH AVE
Subdivision: PP1994 -100 Lot: 1
Project: Smith
Project Description: (1) dishwasher, (1) sink & (1) ice maker for kitchen remodel.
Owner: FEES
SMITH, ROBERT W & JUDITH C TRUST Quantity Description Date Amount
15838 SW 76TH AVE
TIGARD, OR 97224 1 ea Dishwasher 11/05/2009 $25.02
1 ea Ice Maker 11/05/2009 $12.51
PHONE: 1 ea Sink 11/05/2009 $25.02
1 12% State Surcharge - 11/05/2009 $8.70
Contractor: Plumbing
MODERN PLUMBING 10 ea Minimum Fee Adjustment - 11/05/2009 $9.95
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: �' /J_I ng j 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.
' • P ?Nov. 4. 2009 4:51PM VIodern P lumbi ri g No. 6573 P.
rium Dine Permit Application °Z 3
Building Fi xtures NOI 1OR of i'ua; Iasi: ONLY
City of Tigard QQ v JI 301 Received y ,
13125 SW Hall Blvd. ' Tigard, OR 97223 Date/By. ! /�G 9 t%i"�! peRnit N °.: a
1 1 • Phone: 503.639.4171 Fax: 503.598.14OOZ 0 "' Date/ aview
I 1 U A It. n Inspection Line: 503.639.417
Date/By: Other Permit So.:
tcmet: www.tigard or.gov Data Ready/by: r ® ee Page 2 ror
Notified/Method:
A - .. ` ' I ----. % id SupplemenfallnformetSan
TYPE 'OF WO' FEE' 'SCHEDULE
❑ New construction ❑ Demolition for s'scta(in ormation use checklist
Descri r lion
® Addition/alteration/replacement [] Other: 00 Ea.._ Total
New 1- 2- family dwellings (includes 100 ft, for each utility connection)
CATEGORY .OF CONSTRUCTION SFR (1) bath 312.70
J 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi - family SFR (3) bath 500.32
I:1 Master builder Each additional bath/kitchen 25.02
❑ Other: Fire sprinkler ( S. ft.) Page 2
JOB SITE INFORMATION: AND LOCATION Site utilities:
w 1 b i l Catch basin or area drain 18.76
fob site address: 15 D 3 8 S
City /State/ZIP: Tlei P Oyt-- ci - 1 )- a y Drywall, leach lint, or trench drain 18.76
Suite/bldg. /apt. no.: I Project name: Srrti footing drain (no. linear R; ,) Pagc 2
} t Manufactured home utilities 50.03
Cross street /directions to job site: Manholes 18.76
"Tkeyy 5 LTV , 4 e a 5 S G5- _Rain drain connector 18.76
Sanitary sewer (no. linear ft.: Page 2
• r Storm sewer (no, linear ft: ) Page 2
+ Water service (no. linear ft.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map /parcel no.: Backflow prevcnter 31.27
•DESCRfl r10N 016 WORIC ••• • ,; ± a ve 12.51
Baclnvater v 1
�� � Clothes her 25.02 '- Dishwasher 1 25.02 '50)
Drinking fountain 25,02
Ejectors /sump 25.02
O. PROPERTY OWNER ,;' 0; . ; Expansion tank
: 12.51
Name:
- Fixture /sewer cap • 25.02
Address: Floor drain/floor sink/hub _ 25.02
City/Statc/ZIP:
Garbage disposal 25.02
Phone ( ) Fax:(
m
Hose r 25 02
Ice Aker I 12.51 1).51
0 :9PPLICAI!1T : D: CONTA YI • PERSON Interceptor /grease trap 25.02 •
^ Business name: Medical gas (value; $ ) Page 2 .
Contact name: - Primer 12.51
Address - Roof drain_ (commercial) 12.51
Sink/bas 'ato
City/State/ZIP: - Solar units (potable a water) I 62.54 S O �
Phone: ( ) Fax: ! ( ) Tub/shower /shower pan 12.51
E -mail: Urinal 25.02
CONTRAtr I OR 1I Water closet 25.02 -
Business name: MQp PA) 41, /_, Water heater 37 52
Address: 11 Q S T O Water piping/OWV 56.29
L yl a US t , (Ja_ Other: 25.02
City/State/ZIP: 1 1 T
Subtotal (
Phone: ( { 1 (p Fax, (Su 3 (rill I , 0'7 '7 / y
� q Minimum permit fee: $72.50 '7),
CCB Lic.: A d b Plumbing Lic. no.: 3 t SD p Pion review (ZS of permit fee)
! State surch (12% of permit foe) .-.. 70
Authorized Signature:, /[ JM3S � ' _
TOTAL PERMIT FEE pC
Print name- � � k r U - 3- i 11'' ► w Bate: / / t/ - 0 9 This permit applica n it expires hen been if a a permit d as is not comp ta� obned withia 180 day;
� • � G _ �(1 M
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*Fee methodology sot by Tri•Couety lauilding Industry Sorvtce Board. v ` •
r: 1 Bui ldinglpermit8 \PLMr1.NrmltApp.doc 10/01/09 440- 616T(10/021COMPWEB)
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