Permit h 4
CITY OF TIGARD PLUMBING PERMIT
11 q
s , COMMUNITY DEVELOPMENT Permit #: PLM2009 -00175
T t GAR O 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/02/2009
Parcel: 2S114BB13100
Jurisdiction: Tigard
Site address: 16465 SW 104TH AVE
Subdivision: SWANSONS GLEN NO.2 Lot: 72
Project: Moreno
Project Description: Replace 40' of water service.
Owner: FEES
MORENO, JACOB H & MARY E Quantity Description Date Amount
16465 SW 104TH AVE
TIGARD, OR 97223 100 If Water Service 07/02/2009 $55.00
PHONE: 1 12% State Surcharge - 07/02/2009 $8.70
Plumbing
18 ea Minimum Fee Adjustment - 07/02/2009 $17.50
Contractor: Plumbing
JACK HOWK PLUMBING /RESCUE ROOTER
P.O. BOX 2830
CLACKAMAS, OR 97015
PHONE: 503 - 235 -8784
FAX: 503 - 491 -2932
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions t OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: r ` 4 n/ Permittee Signature: n
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
- •DE* -01 -2004 12:58 P.001
Plumbing Permit Application
Building Fixtures RECEI FOK OFFICE USE ONL1
II City of Tigard 6 ego Ll V --Ua 1 I
13125 SW Hall 8l d., Tigard, OR 97223 , I , rte lBt P rrmtl Nn
g JUN 3 0 ZI - :∎t Renew
Phone: 503.639,4171 Fax: 503._08.1060 Other Permit No
Date-B,
Inspection Line: 50) h 3v 41 l 75 C ITY OF T IGA �� I$ See Pa1 2 For
Internet: www.tigard- or.gov
• • Su plementAi Informotion
TYPE OF WORK I r • FEE* SCHEDULE
❑ New construction ❑ Demolition For s, ecial in ormution use checklist.
Desert Lion 111=� rail
L Addition /alteration /replacement ❑ Other; New I- 2- family dwellings (includes Ion ft. for each utilit} connection)
CATEGORY OF CONSTRUCTION SFR i I) bath . 2 -19 Y0
fl I - and 2- Tamil. dwelling ❑ Commercial /industrial SFR (21 bath 35200
Accessory budding
SFR (3) bath 399.00 --
b ❑Multi- lamil.
Each additional bath /kitchen 45,09
❑ Master builder 0 Other: T•-
Fire sprinkler (_ sq. ft. t Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: /d. f 4111 P "'T
Catch basin or area drain 16.60
�� % ifilififf Drvwcll. leach line. or trench drain 16.60
Suite/bldg./apt. no.: Project name: I r� Footing drain (no. linear It.; ) Page 2
Manufactured home utilities 1 10.00
Cross street/directions to job site:
-- -- Manholes 14.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: I Page 2
Storm sewer (no. linear ft.: ) - Page 2
Subdivision: Lot no.: _Water service (no. linear ft.: ✓ 4r Page 2
Tax reap /parcel no.: Fixture or ite
Absorption valve 16,60
�n / DESCRIPTION OF w TC Baekflow preventer Page 2
4 (/ � // 1 /r 1/ per- A Backwater valve 16.60
/ ,64e 2 v . - Clothes washer 16.60
Dishwasher 16.60
PROPERTY OWNER. I ❑ TENANT Drinking fnuntatn 16.60
Name: %/ /14 0 Expansion tank 16.60
Expansion tank 16.60
Address: , r ( 4 (P-S ,J() . -.4j/ Fixture/sewercap 16.60
EBEZIT • V Floor drain/tlour sink/huh 16.60 - iid Phone: ( Q �' - • � —^ ( ) Garbage disposal 16,60
''.1I• APPLICANT Q CONTACT PERSON Hose bib - 16.60
Business mime; ARS dba JACK HOWK / Rescue hooter ice maker 16,60
Contact name: JOYCE DENNIS Interceptor /grease trap
16,60
Medical gas (value: $ ) Page 2
Address: P.O. BOX 283(1 Primer _- I - 16.60
City /State /ZIP: CLACKAMAS, OR 97015 Root drain (commercial) 16.60
Phone: 3 7 0 3 OCR Fax:: (503) 491 -2932 Sink/basin /lavatory 16.60
Tub /shower /shower pan 16.60
E -mail: JOYCE(giJACKhOWK.COM Urinal
16.60
CONTRACTOR Water closet
. 1G.60
Business name: ARS dba JACK HOWK /Rescue Rooter Water heater 16.60 IN
Address: P.O. BOX 2830 Other
City /state /7,[1': CLACKAMAS, OR 97015 — _ Subtotal
r Minimum permit fee: $72.50 WM
Phone: + "- N/fr Fax: (503) 491 -2932 Residential baekflow minimum ermit fee: $36.25
CCB Lie,: 127325 Plumbing Lie. no.: 34 -168 P Plan review (25% of permit fcc) ME
Authorized signature: "eV State surcharge (12% of permit tee) Miejl
> .or TOTAL PERMIT l �A0
Print name: ;� if __ / -_ D � q This permit application expires if a permit Is not ..tai t s • °*
180 days after it has been Accepted as coin , • e,
*Fee methodology set by Tri- County Building Industry Service Board.
1 lnuitding\PermiisiPLMF -P. Please FAX BACK e • 03 -491-