Permit }f t's .. CITY OF TIGARD
PLUMBING PERMIT
7 1
a COMMUNITY DEVELOPMENT
Permit #: PLM2009 -00300
w t Date Issued: 10/21/2009
'TiG 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 1 S 136AD01800
Jurisdiction: Tigard
Site address: 6805 SW PINE ST
Subdivision: Lot: 0
Project:
Project Description: Install backflow device.
Owner: FEES
CARDENAS, MICHAEL Quantity Description Date Amount
6805 SW PINE ST
TIGARD, OR 97223 1 ea Backfow Preventer 10/21/2009 $31.27
1 12% State Surcharge - 10/21/2009 $8.70
PHONE: Plumbing
41 ea Minimum Fee Adjustment - 10/21/2009 $41.23
Plumbing
Contractor:
PIPELINE PLUMBING
PO BOX V -108, 333 S STATE ST
LAKE OSWEGO, OR 97034
PHONE: 503 - 624 -1906
FAX: 503- 624 -1926
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 qu tions OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: (MUM n A Permittee Signature:
AP631
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.
Pl uttibing- Permat A i >tl JR
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Site Utilities O C T 1 9 (] , ' � . h Olt CI I ' 21 . P ti E ` �Q� LI I+ + aw '
1 2009 (Jt�'. +� , "u .,iYk,.Pf, b: d.�t,?k �t��:il..L�r"�.r .!" .- t'SS?..1 ,ei,. _
Vga City of Tigal d PermitNo.: ,t
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a 13125 SW Hall B)v,`.",'r'igard. OR 972 ' ITY OF TIGARD OtbcaPcrm;tNo.:
P m . ' Phone: 503.639.4171 Fax: SOC��y�}. : r� - :
Inspection Line: 503.639.4175 't"T � llh '��_ r'I �I'��� ` i•'
Tate RD` r: RcadYlBy: ) H Sot Page 2for
Internet: www_tigard or.gov Notified/Method: 4 Supplely cola! lnformation
TYPE OF WORK FEE` SCI EDULE
❑ New construction ❑ Demolition For special information use checklist
r - Description 1 Qty. 1 Ea. I Total
�AdditionIalteration /replacement ❑ Other. New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
E{1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
❑ Master builder ❑ Other:
Fire sprinkler ( sq. IL) Page 2
JOB SITE INFORMATION AND LOCATION Slte utilities
Job site address: I.Q fl 05 f" ?ILL,' 37 Catch basin or area drain 16.60
City /State/ZIP: I t c 2l'L( Ca / G ( - t 3 ~ Dr y well, leach line, or trench drain 16.60
Suite/bldg./apt. no.. Project name: Footing drain (no. linear fL: ) Page 2
Manufactured home utilities j 110.00
Cross street/dircctions to job site: Manholes 16.60
l Rain drain cormeclor 16.60
u Sanitary sewer (no. linear fl.: ) Page 2
Storm sewer (no. linear It: _ ) Page 2
Subdivision: lot tso : 1 Water service (no. linear IL: ) Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
DESCRIPTION OF WORK Bacldlow pm-venter 1 Page 2
1175i(.i () O ,f) 0 0 Backwater valve 16.60
/ . P ' ' 6 Lb'� Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 1 16.60
❑ PROPERTY OWNER ❑ TENANT
Ejectors/sump 16.60 -
Name: _ Expansion tank 16.60
Address: Fixlurefsewcr cap 16.60 1
City/State/ZIP: Floor drain/flour sink/hub 1 6.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
Hose bib 16.60
❑ APPLICANT ❑ CONTACT PERSON
lee maker 1 16.60
Business name: Interceptor /grew trap 16.60
Contact name: Medical gas (value: S ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone ( ) !Fax : ( ) Sink/basin/lavatory 16.60
Tub /shower /shower pan 16.60
E-mail: Urinal 16.60 _
CONTRACTOR TR Water closet 16.60
Busine name q\ s ' ) y L ` 1 ,: � ` W7 i IN t: 't. Water heater 16.60
( ` I Other:
Address: 7 � > 0 5 - ' , 't'� ' Y 'l Subtotal
City /State2lP: L -_, �! e ��� Q1 i • t t`; t rip, cA J V L --- Minimum permit fee: 572.50
Phone: (SC ) U j i k._ 1 ( 3 Fax: ("S ) ,ial.,.k \ I. :al:Li Residential backflow minimum permil fee: S36.25
CCB Lic.: c;: r. t t 12 .1 b Plumbing Lic. no.: j`, ) �j" Plan review (25% of permit tee)
r 1 i l State surcharge (12% of permit fee)
Authorized signature: ` L1C+�.u�,j,;' i ' 1 _;/' 1 • \ l TOTAL PERMIT FEE
Print name: j `;` \r, 4, L .,. ?r :;;r' \� ;l' 1 Date: t'vic o el This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
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