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Permit
• CITY OF TIGARD PLUMBING PERMIT - COMMUNITY DEVELOPMENT Permit #: PLM2009 -00245 Date Issued: 09/03/2009 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 2S 103B D 11700 Jurisdiction: Tigard Site address: 12630 SW 121ST AVE Subdivision: Lot: 0 Project: Nix Project Description: Replace 50' of water service. Owner: FEES NIX, MARSHA Quantity Description Date Amount 12630 SW 121ST AVE TIGARD, OR 97223 50 If Water Service 09/03/2009 $55.00 1 12% State Surcharge - 09/03/2009 $8.70 PHONE: 971 - 221 -3551 Plumbing 18 ea Minimum Fee Adjustment - 09/03/2009 $17.50 Plumbing Contractor: RAYBORNS PLUMBING INC PO BOX 69 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 by calling 503.246.6699 or 1.800.332.2344. Issued By: ,�/ / Permittee Signature: (Mr /9"// (// 04/ 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. «4593 691 2328 Rayborns Plumbing 04:19:19 p.m. 09 -02 -2009 2 /24miow Plumbing Permit Applicati Building Fixtures E CEIVED City of Tigard R Da ecei te: B IN ved , y3 G y Permit No. �/t'R00 ? 13125 SW Hall Blvd. Tigard, OR 9722 E P U 240 I r y J / Phone: 503.639.4171 Fax: 503.598.1960 /i Plan Revie DateBy_ Other Permit No.: Inspection Line: 503.639.4175 I ).: : hr 0 See Page 2 for Internet: www.tigand ocgov CITY OF TI 1 N jet Re Notified/ Method: 4e a ; n . I S mental Information TYPE OF + ' FEE* SCHEDULE ❑ New construction ❑ Demolition For spedallgforatadon use checklist Description I Qty. l Ea. 1 Total �� Addition/alteration/replacement 0 Other: New I- 2-family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath - , 249.20 ❑ I- 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 ❑ Othet Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: /, 6 Q f J a 5F. 4 Catch basin or area drain 16.60 City /State/ZIP: 71 a, re, ©f. - q 3 Drywell, leach line, or trench drain 16.60 Suite/bldg. rapt. no.: `� Project name: Footing drain (no. linear ft.: _ ) Page 2 Cross street/directions to job site: Manufactured home utilities ) f0.00 Manholes 16.60 Rain drain connector (6.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: � ) Page 2 Subdivision: L Lot no.: Water service (no. linear ft.: - ' Page 2 Tax map /parcel no.: Fixture or item Absorption valve 161,0 DESCRIPTION OF WORK Backflow preventer Page 2 ,PP /tcrLtra a/el,' " -Se, o.' GF'. Backwater valve 16.60 4`Aie 0-EAre y . 11(t z, r A/S Pc-c.742 Clothes washer 16.60 l 9/4 TD A 1 /1 A Dishwasher 16.60 )�� Drinking fountain 16.60 a r PROPERTY OWNER I ❑TENANT Name: ,,/ � �, Ejectors/sump 16.60 "ea l tl" i/ ri r ' 1 Expansion tank 16.60 r Address: 1a630 St.J t,,,[ 1 { /� �Je . Fixture/sewer cap 16.60 City/ State/ZIP: 7- , Aa ,f ds... er r T7 3 Floor drain/floor sink/hub 16.60 ..l Phone: ( ) 1 3 C V Fax: ( ) Garbage disposal 16.60 APPLICANT Y CI CONTACT PERSON . Hose bib 16.60 Business nano Ice maker 16.60 / S 1 . . Interceptor/grease trap 16.60 Contact name: A)0,..A.,Et a. \'s J Medical gas (value: S Page 2 Address: 1 C4, 0 t✓ ■ 'Do \2 c -6 Primer 16.60 City/ State/ZIP: �� Roof drain (commercial) 16.60 Phone: (g03) 64� ( fit Ic \ I Fax: : (S ) 4 C.(` _j'-Ift Sink/basin/lavatory 16.60 Tub/shower/shower pan 16.60 E- mail: • "`^ Urinal 16.60 CONTRACTOR Water closet 16.60 /� t 7. • r . S III a , + Water heater 16.60 Address: ' (Qq D sw L no t Q Other. City/ State/ZIP: . A t , Q + • S Subtotal � ►ii' Minimum permit fee: $72.50 Phone: ( , = ta�Dr®t'a! Fax: ( ^ .3 ) 6 - - ,_ Residential backt)ow minimum permit fee: $36.25 �� ' �� CCB Lic.: ' g5 Plumbing Lic. n. • (-{- 66 P, Plan review (25% of permit fee) IA Authorized signature: +� /e State surcharge (12% of permit fee) ? , ' " TOTAL PERMIT FEE rte` ✓� / / Date: This permit application expires if a permit is not obtain -. run Q 180 days after it has been accepted as complete. i+ • Fee methodology set by Tri- County Building Industry Service Board. 1 : nuildaw•verm@s.PIM0.Pern,nAyr.doc 0 r. at. 440 -w 101'110 02 COM -WEB)