Permit CITY OF TIGARD PLUMBING PERMIT
'1 COMMUNITY DEVELOPMENT Permit #: PLM2011 -00189
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/14/2011
Parcel: 1 S135CD02500
Jurisdiction: Tigard
Site address: 11835 SW 95TH AVE
Project: CORYELL Subdivision: BOETCHERS ADDITION Lot: 7
Project Description: Replace 100 ft. of water service.
Contractor: RAYBORN'S PLUMBING INC Owner: CORYELL, JACK M SR & ALICE 0 REV
19990 SW CIPOLE RD LIVING TRUST
TUALATIN, OR 97062 12675 SW 111TH PL
TIGARD, OR 97223
PHONE: 503 - 692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
100 If Water Service 06/14/2011 $62.54
Specifics: 1 12% State Surcharge - 06/14/2011 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment - 06/14/2011 $9.96
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 1.800.33 .
Issued By: Permittee Signature:
Ca 9.4175 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 09:49:58 a.m. 06 -13 -2011 1 12_
03 691 2328 Rayborns Plumbing
Plumbing Permit Application FiEC� vn
Building Fixtures FOR' OFFICE 1 sr, f)NLv
City of Tigard JUN 1 4 2011 Received , I Permit LOrs I
l w • 13125 SW Hall Blvd., Tigard, OR 97223 Date.B i No U PI_
Phone: 503.639.4171 Fax: 503.598.1960 CITY ,.I Plan Review
OF TlGr''1 Dale /By: Other Permit No.:
'I ht A R n Inspection 503.639 •
Line: .4175
BUILDING v Date Read !e
Internet: Line: gard- or.gov BUIL DING DI VISI(,•.r y y Jura. PI See Page 2 for
Noti6ed'Method: I i a Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New • struction ❑ Demolition For special information use checklist.
% Addition /alteration /replacement ❑Other: Description I Qty. I Ea. I Total
New I- 2- family dwellings (includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ Multi - family
❑ Master builder Each additional bath kitchen 25.02
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: , 3 / Catch basin or area drain 18.76
City/State/ZIP: •, Drywell, leach line, or trench drain 18.76
4' r q
Footing drain (no. linear ft.: �) Page 2
Suite/bldg. /apt. no Project name: J
�l Manufactured home utilities 50.03
Cross street/directions to job site: Q 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.; /a) Page 2
Fixture Subdivision: Lot no.: /-
xture or item:
Tax snap /parcel no.: Backtlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
��� Clothes washer 25 02
��4z 1 /.e,- . �y rviCs //AO 4.1 Dishwasher
25.02
Drinking fountain 25.02
Ejectors /sump 25.02
-
❑ PROPERTY OWNER I ❑ TENANT Expansion tank
12.51
Name: Fixture/sewer cap 25.02
Address: Floor drain/floor sink/hub 25.02
Garbage disposal 25.02
City /State /ZIP:
Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker o
I� 51
❑ APPLICANT R CONTACT PERSON Interceptor /grease trap 25.02
Business name: �
/ /v 6r - Medical gas (value: $ ) Page 2
�. .1 4
Contact name: Na Kett ; LA, 12.51
/ Roof drain (commercial) 12.51
Address: /7 �QO SW r
Sink/basin/lavatory 25.02
City/State! "LIP: .
,. /e e2 7 3 Solar units (potable water) 62.54
Phone: (, ) 3) , 72- q Fax:: (3) 6Cfl .....Pg Tub /shower /shower pan 12.51
E -mail: ' '/ �> ii / arm S . e..,,,,,_-... Urinal 25.02
(� CONTRACTOR Water closet 25.02
�
1 v , - Water heater 37.52
Business name: I ,� ✓ `
Water piping/DWV 56.29
Address: s c. ef3(P Re...t. Other: 25.02
City /State /ZIP: obi \a a•r . Q. 47062 Subtotal
Phone: (5 J _ q ( 3 ' Fax: ( 6 Cll _ �3Dg Minimum permit fee: $72.50
CCB Lic.: � Q�� ^ 16g J� permit review (25% of permit fee)
Plumbin_ Lic. no.:
� � State surcharge (12% of pmit fee)
Authorized signature: �� i ... ''
�' � ���' y TOTAL PERMIT FEE
Print name: . 4/ 4 / r , / ,e. 'ice, v - cs f& o,, Date: 6 -13 1 I This permit application expires if a permit is not obtained wl n 180 days
I after It has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
I Budding to ts.,PLMU -Penn it App.doe 10.01,09 440- 4016T( 10 WEB)