Permit CITY OF TIGARD PLUMBING PERMIT
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_ COMMUNITY DEVELOPMENT Permit #: PLM2011 -00163
Date Issued: 05/25/2011
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439
Parcel: 2S 103BCO3200
Jurisdiction: Tigard
Site address: 12270 SW ALBERTA ST
Project: Nash Subdivision: CANOGA PARK Lot: 6
Project Description: Replace bath tub with walk in tub.
Contractor: RAYBORN'S PLUMBING INC Owner: NASH FAMILY REV LIV TRUST
19990 SW CIPOLE RD BY DOUGLAS E /NANCY LOU NASH TRS
TUALATIN, OR 97062 12270 SW ALBERTA AVE
TIGARD, OR 97223
PHONE: 503 - 692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
1 ea Tub /Shower /Shower Pan 05/25/2011 $12.51
Specifics: 1 12% State Surcharge - 05/25/2011 $8.70
Plumbing
Type of Use: SF 60 ea Minimum Fee Adjustment - 05/25/2011 $59.99
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 Notification Center. 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 questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
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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.
503 691 2328 Rayborns Plumbing 12:11:49 p.m. 05 -23 -2011 1 /2aa.rnam
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Plumbing Permit Applicati 0 I
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Building Fixtures MAY 2 3 2011 1'(.)R OFFICE. USE ONIA' . '
City of Tigard n Received r�
r I V rIL ai I t l � Date /By:. -9 3% Permit No/ 4''-# /6;3
i 13 125 SW Hall Blvd., Tigard, OR 97 9
■ ' Phone: 503.639.4171 Fax: 503.g�� INg�G/� ' f S a „ Plan Review ��� / /rao / Z
:3EJiIIV1:1 DIVISION DateiBy: Other Permit No.
T I ti A it I Inspection Line: 503.639.4175 Date Ready /By: 1 See Page 2 for
Internet: www.tigard or.gov Notified, M ethod: (.V Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑Demolition For special information use checklist
Descri rtion • . Ea. Total
VAddition/alteration/replacement ❑ Other: New I- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
11- and 2-family dwelling SFR (2) bath 437
Y g ❑ Commercial /industrial
❑ Accessory building ❑ Multi - family SFR (3) bath 500.32
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: { , a'7 0 5 A I b, - 5+ Catch basin or area drain 18.76
1 Drywell, leach line, or trench drain 18.76
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City /State /ZIP: " OR l e 3 Footing drain linear , Page 2 n
Q � r oot n (no. near ft.: ) Pa g
Suite/bldg. /apt. no.: Project name:
Wok eS 1 v Manufactured home utilities 50.03
Cross street /directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft.: _) Page 2
Water service (no. linear ft.: `) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map /parcel no.: BackFlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
kt • (f: • 16 Vi % V- I k I'` Tvi2. Dishwasher 25,02
Drinking fountain 25.02
Ejectors /sump 25.02
0 PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: 4414S21f Fixture/sewer cap 25.02
Floor drain/floor sink /'hub 25.02
Address: �+ _
*� �M Garbage disposal 25.02
City /State /ZIP:
Hose bib 29
Phone: ( ) Fax: ( ) Ice maker
1_51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25
Business name: Medical gas (value. S ) Page 2
Contact name:
Primer 12.51
-- - Roof drain (commercial) 12.51
Address:
_.- Sink/basin/lavatory 25.02
City. /StateiZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower/shower pan ___r_1 12.5 t f
E -mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37 52
Business name:
orris P t/Itti ) zhL __ Water pipingDWV 5629
Address: • 0 • 0 R
Other: 25.02
EZIEINNIM ' 0 . ( ) 1 6 Subtotal (.).S.- I
Phone: ( 4/3) , ' .)..- I'S 111111111 Fax: a5) 10) - ,, 3. ,] Minimum permit fee: S72.50 '7, . A 2' _sot
Lie.: 676 Plumbing Lic, no,: 3��f�(7 PB _ Plan review (25 %ofpernit fee) la 0
State surcharge (12% of permit fee) Ato '10 �� 7
Authorized signature:, �_ �/ , ��
/ TOTAL PERMIT FEE A • sA
Print name: J / • t1✓ Date: Sa3 If This permit application expires if a permit is not obtained hin 1 :0 . ays
after it has been accepted as complete.
"Fee methodology ,et by Tr:- County Building Industry Service Board.
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