Permit ,� CITY OF TIGARD PLUMBING PERMIT
1 11 2 COMMUNITY DEVELOPMENT Permit #: PLM2010 -00309
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/22/2010
Parcel: 2S103DA03902
Jurisdiction: Tigard
Site address: 10965 SW MIRA CT
Subdivision: Lot: 0
Project: Libin
Project Description: Irrigation backflow.
Owner: FEES
LIBIN, ALAN Quantity Description Date Amount
10965 SW MIRA CT
TIGARD, OR 97223 1 ea Backflow Preventer 09/22/2010 $31.27
1 12% State Surcharge - 09/22/2010 $8.70
PHONE: 503 - 747 -5851 Plumbing
41 ea Minimum Fee Adjustment - 09/22/2010 $41.23
Plumbing
Contractor:
LEWIS LANDSCAPE SERVICES, INC.
6107 SW MURRAY BLVD., #108
BEAVERTON, OR 97007
PHONE: 503 - 524 -3679
FAX: 503 - 213 -5921
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: Permittee Signature: e m/ O� 1„ / �►,5-
CaII 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 R -e
Building Fixtures 1 < <01 0
IN City of Tigard 13125 SSW Nall Blvd., Tigard, OR 97223 S ` c-` G � ..�, 81 � sZ /0 Permit xo.:A �0 /D do n y
C�
C ' Phone: 503.639.4171 Fax: 503.598.1960 Cl' G�1 :1`I�',Datday: Other Permit No.:
Insp Line: 503.639.4175
I' i GA R f? Q ````lL�1N Date ReadyBy:��I HI See Page 2 for
Internet: www.tigard-or.gov ] ry Notified/Method: - 1 ` Supplemental Information
TYPE OF WORK 1 1FEE* SCHEDULE
I For special Informasion use rJteeklist
❑ New construction j Demolition Description 1 Qty. I Ea. 1 Total
® Addition/alteration/replacement f ❑ Other. New 1- 2-family dwellings (includes 100 R. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
® 1- and 2- family dwelling ❑ 437.78
.
Commercial/industrial SFR (2) bath SFR (3) bath 500.32
❑ Accessory building ❑ Multi-family Each additional bath/kitchen 25.02
0 Master builder ❑ Other. Fire sprinkler ( sq. 11.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Catch basin or area drain 18.76
Job site address: 10965 SW Mira Ct. Drywell, leach line, or trench drain 18.76
CitylState/ZTP: Tigard, OR. 97223 Footing 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.: 1 . Page 2
Storm sewer (no. linear ft.: _ Page 2
. Water service (no. linear ft.: _) Page 2
Subdivision: Lot no.: Fixture or item: 1
Backllow preventer 1 31.27 31.27
Tax map/parcel no.: Backwater valve 1-51
DESCRIPTION OF WORK
Clothes washer 25.02
Install back flow preventer Dishwasher 25.02
Drinking Rwntain 25.02
Ejectors/snmp 25.02
Expansion tank 12.51
® PROPERTY OWNER I ❑ TENANT
Fixture/sewer cap 25.02
Name: Alan Libin Fixture/sewer
drain/floor sink/hub 25.02 ,
Address: 10965 SW Mire Ct Garbage disposal 25.02
City/State/ZIP: Tigard, OR. 97223 Hose bib 25.02
Phone: (503)747-5851 Fax: ( )
Ice maker 12.51
® APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: 8 • ) 1 Page 2
Business name: Lewis Landscape Services Inc. 12.51
Primer Contact name: Jim Lewis Roof drain (commercial) 12.51
Address: 6107 SW Murray Blvd #I08 Sink/basin/lavatory 25.02
CitylStater7_TP: Beaverton, OR. 97008 I Tub/shower /shower _
Solar units (potable water) 62.54
pan 12.51
Phone: (503)524 -3679 I Fax: : (503) 213 -59ZI 25.02
1 Urinal
E -mail: jirn@lewislandscape.com Water closet 25.02
CONTRACTOR Water heater 37.52
Business name: Lewis Landscape Services, Inc. Water piping/DWV 56.29
Address: 6107 SW Murray Blvd. #10S Other: i 25.02
Subtotal 31.27
City /State/ZIP: Beaverton, OR. 97007 Minimum permit fee: $72.50
outs (503) 524 -3679 Fax: (503) 213 - 592 1
Plan review (25% of permit fee)
U .. - "B Lie.: 8112 / 3/ 11 - 1 ..bing Lie. no.:"
. 5 iy75 -6 State surcharge (12% of permit fee)
Authorized signature: EMPW y6 L/ e - TOTAL PERMIT FEE 81.20. ✓ I. � .�. This permit application expires if a permit is not obtained within 180 days
Print name: Jim Lewis Date: 921/10 after it has been accepted as complete.
'Fee methodology set by Tri-County Build Industry Service Board.
1s 1saading1Pe,mitaWLMU-PermitApp.doc 10ro1a9 4404616T (10( COMAVEB)
L'd LZ69£ LZ£09 s!Mel dO9:Z0 01. 6Z deS