Permit CITY OF TIGARD PLUMBING PERMIT
o COMMUNITY DEVELOPMENT Permit #: PLM2010 -00335
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/19/2010
Parcel: 2S104CA11700
Jurisdiction: Tigard
Site address: 13660 SW WESTRIDGE TER
Subdivision: HILLSHIRE Lot: 117
Project: Herkemij
Project Description: Moving water closet, shower and sink to new locations.
Owner: FEES
HERKEMIJ LIVING TRUST Quantity Description Date Amount
13660 SW WESTRIDGE TER
TIGARD, OR 97223 1 ea Sink 10/19/2010 $25.02
1 ea Tub /Shower /Shower Pan 10/19/2010 $12.51
PHONE: 1 ea Water Closet 10/19/2010 $25.02
1 12% State Surcharge - 10/19/2010 $8.70
Contractor: Plumbing
RAYBORN'S PLUMBING INC 10 ea Minimum Fee Adjustment - 10/19/2010 $9.95
Plumbing
19990 SW CIPOLE RD
TUALATIN, OR 97062
PHONE: 503 - 692 -4139
FAX: 503- 691 -2328
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: " Permittee Signature: ,,,
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
-503 691 2328 Rayborns Plumbing 10:06:43 a.m. 10-19 -2010 1 /2
Plumbing Permit Applicatio C 01 �
Building Fixtures Z9 ti 1(JU (,EPIC. 1. (SI� 0\1.1
City of Tigard ,o�j' 1 Ve d
-'$ i Permit No
13125 SW Hall Blvd., Tigard, OR 97223 �" • 10 ll t/. a. 1 ��
1 Q Plan Review
Phone: 503. 639,4171 Fax: 503.598.1960 C �' Other Permit No.:
I . 1 i. , ,\ 1t � Inspection Line: 503.639,4175 ' Date /By:
Date Ready/By: . J . � ura: � 61 See Page 2 for
'
Internet: www.tigard - or.gov Notified /Method: / r` f' Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description 1 Qty. 1 Ea 7 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
and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bathrkitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler( sq. ft) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: /3a- O 5 - 14 / J ri d e 1 ev Z e Catch basin or area drain 18.76
City / State/ZIP: t O� S 1
Footing 1, leach line, trench drain 18.76
Footin drain (no. linear ar ft-: _) Page 2
Suite/bldg. /apt. no.: Project name: .. , i 1 Manufactured home utilities 50.03
Cross street /directions to job site: vv�� v 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: Lot no.: Fixture or item:
Tax map /parcel no.: Backtlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12
` Clothes washer 25.02
4j/e- / 74; I e } Moue_ C4- uCJ- 1&.540A\ Dishwasher 25.02
Uh /.549tve Moue (OW in 4e l.t) Drinking fountain 25.02
10G,,, G v.-. Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: Fixtureisewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: �J�„ , ' loofa ' S b e ` & Medical gas (value: $ _ ) Page 2
``t�/ y Primer 12.51
Contact name: A e 11'' --
T 1�> (Ars 1A..- Roof drain (commercial) 12.51
Addres O S \ el Sink/basin/lavatory / 25.02
City/State/ZIP: v „ L ` _` W � Q Ck 7O 2L Solar units (potable water) 62.54
Phone: (i.; ) A D_ (..t ` 3er ( Fax: : (,o3) 64 i _ Tub /shower /shower pan / 12.51
E -mail: //'{e a) (ay6OVV% ft 1. ki-L- Urinal 25.02
CONTRACTOR Water closet 25.02
t Water heater 37.52
Business name: R pt7✓vt S �l� 1 Water pipinglDWV 56.29
Address: ( 'ICAO 7 SW G e gAe RI Other: 25.02
City/State/ZIP: ‹., �; (/L- r € 7O6-- Subtotal
Phone. (403 ) i ( � 2_ (11 3q Fax: (O3) 61 ( - Minimum permit fee: $72.50 72 %-)
CCB Lic.: 0 g i , Plumbin' ic. no.: 34 - 166 P5 Plan review (25% of permit fee)
State surcharge (12% of permit fee) • "7i7 A
Authorized signature: / /// 7 / / ,'i - 7)
TOTAL PERMIT FEE 3C(r
Print name: " r Date: / - /r.70 ( b Thb permk application expires if a permit not obtained wit 180 days ✓!/
/ / . i- le r ttti � I� after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
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