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Permit
CITY OF TIGARD PLUMBING PERMIT s COMMUNITY DEVELOPMENT Permit #: PLM2009 -00178 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07(07(2009 Parcel: 2S103BB10600 Jurisdiction: Tigard Site address: 12140 SW 123RD CT Subdivision: YE OLDE WINDMILL Lot: 26 Project: Wittkop Project Description: Install residential backflow preventer for irrigation system. Owner: FEES WITTKOP, JAMES G AND Quantity Description Date Amount PATRICIA A, 12140 SW 123RD COURT TIGARD, OR 97223 1 ea Backflow Prevention - RES 07/07/2009 $27.55 PHONE: 1 12% State Surcharge - 07/07/2009 $4.35 Plumbing 9 ea Minimum Fee Adjustment - 07/07/2009 $8.70 Contractor: Plumbing OWNER PHONE: FAX: Type of Use: SF Class of Work: OTR Type of Const: Occupancy Grp: Stories: Total $40.60 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 dire questions . sUNC by calling 503.246.6699 or 1.800.332.2344. Issue By: Permittee Signature: „ Call 503.639.4175 by 7:00 a.m. for an inspection that busi ss 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 Building Fixtures FOR OFFICE USE ONLY City of Tigard Received Date/By: ? l e i Permit No.: Lit - ef 1 0 / rail • 13125 SW Hall Blvd., Tigard, OR 97223 II I Phone: 503.639.4171 Fax: 503.598.1960 Plan Review Date/By: Other Permit No.: Inspection Line: 503.639.4175 Date Ready/By: Jur s: to See Page 2 for T 1 G AR D Internet: www.tigard - or.gov Notified/Method: Supplemental Information 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- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 249.20 g 1- 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 ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities Job site address: /"a/ v) SLR / „ 2 3 Rd (. Catch basin or area drain 16.60 City /State/ZIP: 7 / ewe 77o2(A3 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: _) Page 2 Manufactured home utilities 110.00 Cross street /directions to job site: Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: _) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer J Page 2 A7. b ie z / A , - fj z) Re at4/ Backwater valve r 16.60 0 X- S�R/it//e/I y . 7/3 / JJGL . Clothes washer 16.60 Dishwasher 16.60 Drinking fountain 16.60 jk PROPERTY OWNER ❑ TENANT Ejectors /sump 16.60 Name: ,IYJ�s e' h Expansion tank 16.60 Address: / 2/ VO SU.) /23 "t GT Fixture /sewer cap 16.60 City /State/ZJP: - /�2d e:,/e gp.4/ ?7 Floor drain/floor sink/hub 16.60 Phone: („9 ) .eY9 3('3 Fax: ( ) Garbage disposal 16.60 t kr APPLICANT Hose bib 16.60 ❑ CONTACT PERSON Ice maker 16.60 Business name: /� Interceptor /grease trap 16.60 Contact name: � (4 / //HOP Medical gas (value: $ ) Page 2 Address: 42 / ' ) 4 to / Z 3 'E'd e 'T Primer 16.60 City/State/ZIP: / �g� © s ye 97a Roof drain (commercial) 16.60 , � / tJ Sink /basin/lavatory 16.60 Phone: ( ) Fax:: ( ) Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name: ! /eey,2r'/1 ),, off7: L.JtiCee_ Water heater 16.60 Address: Other: City /State/ZIP: Subtotal Minimum permit fee: $72.50 JJ Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 C • CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (12% of permit fee) • Authorized signature: T / TOTAL PERMIT FEE lit) . 40 Print name: N24/11/5 s bel . l Date: 7/74 This permit application expires if a permit is not obtained withm / f 180 days after it has been accepted as complete. *Fee methodology set by Tri- County Building Industry Service Board. I:\Buildng\Permits\PLMF- PermitApp.doc 12127/06 440- 4616T(10/02/COM/WEB)