Permit s y p CITY OF TIGARD PLUMBING PERMIT
`• COMMUNITY DEVELOPMENT Permit #: PLM2009 -00267
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/29/2009
Parcel: 1 S133DD12800
Jurisdiction: Tigard
Site address: 11881 SW 126TH PL
Subdivision: VILLAGE AT SUMMER LAKE PARK 4 Lot: 165
Project: Jimerson
Project Description: Repipe residence.
Owner: FEES
JIMERSON, DAVID A Quantity Description Date Amount
11881 SW 126TH PL
TIGARD, OR 97223 73 da Misc Other Fee 09/29/2009 $72.50
PHONE: 1 12% State Surcharge - 09/29/2009 $8.70
Plumbing
Contractor:
ANSPACH PLUMBING INC.
18380 S. FERGUSON RD.
OREGON CITY, OR 97045
PHONE: 503 - 789 -3913
FAX: 503 - 631 -7972
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 o ain 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.
)PInmbin Permit Applicat IAlO 9Nlal(f18
S ite Utilities Qavoll JO Al10 FOR OFFICE USE ONLY
City of Tigard Received Q
t - • 13125 SW Hall Blvd., Tigard, OR 9' i Z 6 Z d 3 S DateBy: ' � 9 ,4 L Permit No. > 6 09 - ziOo L i
Phone: 503.639.4171 Fax: 503.598.1 ' , 1 - DateBy: an Revt Other Permit No.:
inspection Line: 503.639.4175 133 TIGARD Ready /By: Date R B luris 1 B Se e Page 2 for
T
Internet: www.trgard -0t.gOV g Notified/Method: j Supplemental lemeotal information
TYPE OF WO ' ":'i FEE* SCHEDULE
`
[View 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
1- and 2- family dwelling ❑ CommeroiaVindustrial SFR (2) bath 350.00
Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑� Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
/Job site address: 1 1$11 I n 5' W /2 6 f /. Catch basin or area drain 16.60
City/State /ZIP: Ti. j 0 k T 7 2 z3 Drywell, leach line, or trench drain 16.60
Footing drain (no. linear ft.: ) Page 2
Suite/bldg,�apt. no.: I Project name:
• Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: _J Page 2
Storm sewer (no. linear ft.: _J 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 Page 2
P ( Q l p A h c Ou S-(% Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: 17 cuLt ,i cj) U vY i 4 (.) ,) Expansion tank 16.60
Address: 1[ p f i 3� j 26 f I Fixture/sewer cap 16.60
City/State/ZIP: O 71.4 r or< '9 7Z Z3 Floor drain/floor sink/hub 16.60
Phone: ( )
Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) I Fax:: ( )
Sink/basin/lavatory 16.60
Tub /shower/shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
.
Business name: 1- nSp C. e / 1 �, o e - Water heater 16.60
Address: \i3 bD ..S , . f 'r U st lc, Other: /'E/- n/° /A/6.-
City/State/ZIP: 0 rP O n C) l V 0 l Subtotal
y l Minimum permit fee: $72.50
Phone: (563 ) 7 _ ( � 1/ 3 Fax: (563) 6 3 / - 7 y 7 Z Residential backflow minimum permit fee: $36.25 /a . -) v
CCB Lic.: / 6 3 7 7 yl/ ' / 11juc no_Vz P8 _ Authorized signature: /� a ! 2/11 i' State surcha (12% of permit fee) 1 7d
Gyci 1 TOTAL PERMIT FEE ff /, a 0
Print name: /Via < tav I Date: 74101 This permit application expires if a permit is not obtained within
`l "` 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I:\ Building \Pennits\PLMU - PermitApp.doc 12/27/06 440- 46I6T(10/02/COM/WEB)