Permit CITY OF TIGARD PLUMBING PERMIT
11 COMMUNITY DEVELOPMENT Permit #: PLM2011 -00079
f G AR L7 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/16/2011
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Parcel: 1S134 DC10800
Jurisdiction: Tigard
Site address: 11853 SW 113TH PL
Project: Campbell Subdivision: PP1991 -044 Lot: 1
Project Description: Installation of residential backflow preventer for irrigation.
Contractor: JUANES LANDSCAPE Owner: CAMPBELL, JENNIFER C TRUST
6611 SE 97TH AVE 11853 SW 113TH PL
PORTLAND, OR 97266 TIGARD, OR 97223
PHONE: 503 - 956 -9328 PHONE:
FAX: 503 - 775 -1345
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 03/16/2011 $31.27
Specifics: 1 12% State Surcharge - 03/16/2011 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment - 03/16/2011 $41.23
Plumbing
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 Notificatio . Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or direct que ons to OUNC by ca . qg 503.232.1987 or 1.800.332.2344.
'6 Tk/ Issued By / / i1/ i / L � / ,,J k„ Permittee Signature: C-Vik GO (-0 7 C r)
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
C 6F 4.
1 . , < 1 . Plumbing Permit Application OFFICE USE ONLY
` -- :..\ City of Beaverton Community Development Date Received: ��1� Permit No.: � 1 -0607 . PO Box 4755, Beaverton, OR 97076
- Phone: (503) 526 -2403; Fax: (503) 526 -2550 Date Issued: By:
%"'`'tFMNNw` Internet address: www.beavertonoregon.gov Payment Type:
TYPE OF WORK FEE SCHEDULE
❑ New construction ❑ Demolition For special information, use checklist.
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ❑ Other: New 1 dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 242.00
[] 1- and 2- family dwelling ❑ CommerciaUindustrial SFR (2) bath 278.30
❑ Accessory building ❑ Multi - family SFR (3) bath 314.60
❑ Master builder Each additional bath/kitchen 29.05
❑ Other: Fire sprinkler ( sq ft.) *
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: l' iS3 ,s W ` I , 7 i c2( Catch basin or area drain 12.60
City/State /ZIP: J ) qq,� 6S\ 9 7 Z3 Drywell, leach line, or trench drain 12.60
J Footing drain (no. linear ft.: )
Suite/bldg. /apt. no.: Project name: Manufactured home utilities 12.60
Cross street/directions to job site: Manholes 12.60
Rain drain connector 12.60
Sanitary sewer (no. linear IL: _) *
Subdivision: Lot no.:
Storm sewer (no. linear ft.: ) *
Water service (no. linear ft.: ) *
Tax map /parcel no.: Fixture or item
DESCRIPTION OF WORK 1 Absorption valve (water hammer) , 12.60
1A a ■r s c G Backflow preventer / -.2 .3l, a 7
Backwater valve 12.60
Clothes washer 12.60
Dishwasher 12.60
Drinking fountain 12.60
ID PROPERTY OWNER , ❑ TENANT Ejectors /sump 12.60
N a m e : ( - i � CqM Q kJ) Expansion tank 12.60
Address: 1 / 853 5 I I 1 1 ` 7 vt, Fixture/sewer cap 12.60
- W Floor drain/floor sink/hub 12.60
-�--
City/State /ZIP: I acc (- V\ ?? 7_23 Garbage disposal 12.60
Phone: 5 O 5 -4'26 -27 37 Fax: Hose bib 12.60
❑ APPLICANT °' 0 CONTACT PERSON
:. Ice maker 12.60
Business name: T� os ,(\P 5 h a Ii\/' S c Ck p P Interceptor /grease trap 12.60
Contact name: �_ J �� fl \ Medical gas (value: $ )
Primer 12.60
Address: 6 / I 5 77 / U 4 Roof drain (commercial) 12.60
City/State /ZIP: q p i.z (3‘ 972 ‘ 6 Sink/basin/lavatory 12.60
Phone: aS3 - 7.5 1 .- 73 2? Fax:: 5 3 ^ 9 7s -- /? ( Sump 12.60
E -mail: Tub /shower /shower pan 12.60
- CONTRACTOR Urinal 12.60
Water closet 12.60
Business name: c c S C C L.,Q) SC
O / 5 7 /4 A V k m
Water heater 12.60
Address: 5
/ Water meter pvt 12.60
City/State /ZIP: %t5 c \ I c 6� a 7 14 6 Other: 12.60
Phone: 563 - 75 4 2 Fax: SG'S -7 73 -13 4/3 Subtotal
E -mail: Plumbing. lic.: Minimum permit fee 7� ._ .� .3 Q
( �� Plan review ( 25% of permit fee) _---
CCB lic.: LC 8 841 �I' / A/ 3 City or metro lic. no.: State surcharge (12% of permit fee) Q 7
Authorized '� TOTAL PERMIT FEE r
signature: v t5 Ck 1� ` S �� C. Q This permit application expires if a permit is not ob rued within
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180 days after it has been accepted as complete /
Print name: ) (� <:).-7 < O Date - 4'- / ( * See Fee Schedule �[
J 440 -4616T (8 /05 /COM/WEB) Revised 10/09