Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00172
1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/03/2011
IICrARU Parcel: 2S 110DD06700
Jurisdiction: Tigard
Site address: 10535 SW GREENLEAF TER
Project: Thompson Subdivision: SUMMERFIELD NO 5 Lot: 292
Project Description: Relocate (2) lays
Contractor: RAYBORN'S PLUMBING INC Owner: THOMPSON, LELA M
19990 SW CIPOLE RD 10535 SW GREENLEAF TER
TUALATIN, OR 97062 TIGARD, OR 97224
PHONE: 503 -692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
2 ea Lavatories 06/03/2011 $50.04
Specifics: 1 12% State Surcharge - 06/03/2011 $8.70
Plumbing
Type of Use: SF 22 ea Minimum Fee Adjustment - 06/03/2011 $22.46
Class of Work: ALT Plumbing
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:
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.
. 12:30.20 p.m. 06 -02 -2011 1 /2�
503 691 2328 Rayborns Plumbing
Plumbing Permit Appeatiuncllirrn
Building Fixtures HELIL u V .��t FoR OFFICE l:sr ONLY
City of Tigard II IIN�J 2 2011 ived
;� • 13125 SW Hall Blvd., Tigard, 0 DR ece ate:'B : fr j A r , Permit No.P ` �/ 0 0/°,
Phone: 503.639.4171 Fax: 50 .59� 1960 Plan Review
p P 1 Vt- i ICA 'RD
Date/By:
Other Permit
T I G A RD Ins ection Line: 503.634.41 1 "�� 't ty Dare Ready/By:
Internet: www.tigard- or.g0�v��ii t l(NG Di \flSIO yr� S See Pen l for
� Notified�Method: � / f L Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description i Qty. I Ea. 1 Total
Nig. Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 10011. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (I) bath 312.70
*1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
ID 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: or r Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
i c42 r
Suite/bldg./apt. no.: Project name: i Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 50.03
Cross street/directions to • Manholes 18.76
d S - s - /7 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.: Backtlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
rvtouI / AOS Clothes washer 25.02
L Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
it PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: A-AN Fixture /sewer cap 25.02
Address: 1 l p� Floor drain /floor sink/hub 25.02
` -'i-+ teer Garbage disposal 25.02
City /State /ZIP: l D. g7Ji.ti
7 Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker
12,51
❑ APPLICANT
❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ _) Page 2
Contact name: Primer 12.51
Address:
Roof drain (commercial) 12.51
Sinkbasinilavatory 25.02 50 ay
City /State /ZIP: Solar units (potable water) 62.54 •
Phone: ( ) Fax:: ( ) Tub /shower/shower pan 12.51
E -mail: Urinal 25.02
CONTRA OR W'atercloset 25.02
Business name: l / Water heater 37.52 1
41 apJ '� ' .A.,_:,
Water piping%DW'V 56.29
Address: /t ! rr i . 4 Other: 25.02
City/State/ZIP: /
L�/ b-- f g gl6 Subtotal a
Phone: (5-0 3 61 4- yaq Fax: 3 /g`-4 • Minimum permit fee: 572.50 ^ 7L•�
CCB Lie.: A. Pl in Lic. n O " //�,, Plan review (25% or pennit fee)
-, g o Ar' Gw��
,� State surch (12% of permit fee) 7�
Authorized signature: r7 �'. ,c7
�� TOTAL PERMIT FEE
Print name: r t , [. / 1 r 1 Date: iy� This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
'Fee methodology set by Tri- County Roild eg Industry Service Board.
I: n Permits PI_MU- PnmitApp -dos 1001 0,) 44OJ61ST(I0.02,C'OhyW1.8)