Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00246
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/28/2011
Parcel: 2S 103BC04000
Jurisdiction: Tigard
Site address: 12490 SW WALNUT ST
Project: Subdivision: Lot:
Project Description: Replace 40' of water line.
Contractor: PIPELINE PLUMBING Owner: CAMERON, DONNA IRENE
333 S STATE ST, STE. V -108 12490 SW WALNUT ST
LAKE OSWEGO, OR 97034 TIGARD, OR 97223
PHONE: 503 - 624 -1906 PHONE:
FAX: 503 - 624 -1926
FEES
Quantity Description Date Amount
40 If Water Service 07/28/2011 $62.54
Specifics: 1 12% State Surcharge - 07/28/2011 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment - 07/28/2011 $9.96
Plumbing
Class of Work: OTR
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: �// ? 1 Permittee Signature: �/ 9— '/' zir��77.m V
l( � 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.
Feb 26 00 02:41a p.1
Plumbing Permit Application ECEI
Building Fixtures FOR OFFICE USE ONLY
JUL 2 6 2011 Receive PermitNo,PUyadi o aayb
City of Tigard J �t�gatcll3yy.
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■ 13125 SW Hall Blvd., Tigard OR(` OF Til ilil' Re icw Other Permit No.:
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Phone: 503.639.4171 Fax: 503.598.�r0
Inspection Line: 503.639.4175 ILDI DIVISION Date Ready/By: t H sre ragezfor
S G � www.tigard-m.gov and -ou. lemeutat tnformnt
Internet
g Noti6e dlMethod: S ppP
TYPE OF WORK .FEE*: SCHEDULE
❑ New construction 1:1 Demolition
For sf special UIformaPrarr use checklist
Description I Qty. 1 Ea. 1 Total
9 ddition/alteratian/repiacement ❑ Other: New 1- 2- family dwellings (includes 100 R far each utility connection)
CATEGOR OF CONSTRUCTION SFR (1) bath 249.20
an
nd 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.) Pagc 2
JOB SITE INFO' IATION AND LOCATION Site utilities •
Job site address: 2t5, I D. ` 0 Si) » t.LT S-1-- Catch basin or area drain 16.60
City/State/7_1P: Tt Zy i r 4 . 64 a D. 3 Drywell, leach line, or trench drain I6.60
Suite/bldg./apt. no_: Pro canaille: 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
1 • Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: 1 Lot no.:
Water service (no. linear ft.: £/O ) i Page 2
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
I) ' t• ON OF WORK : , ' . Backflow preventer Page 2
11� tC.4 v ltr OL Sc- (
) t9 : Oh _ 1 Backwater valve 1 6.60
LL I ^ • l t Q , J h - 0 _ 1.- .. Clothes washer 16.60
` f 1 1 13 +Y 1[ � Dishwasher 16.60
PROPERTY * OWNER I ❑ TENAppF Drinking fountain 16.60
Ejectors/sump 16.60
Name: I e 6-M & 4 I Ai 2514/1/Ain- Expansion tank 16.60
Address: M Fixture/sewer cap 16.60
City /State/ZIP: 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: t' '17 ,,\ v . 2, iy 1 II 1,'") iie'C) Interceptor /grease trap 16.60
Contact name: L. (� � C t( 71,---..i. Medical gas (value: S ) Page 2
. Address: 37: r . �. 1 CS, 5-2 _ FA . 7i, \ „ r, 3< . -i 1 '-`'� Primer 16.60
CityJState/ .LP: C 1;
Phone: LL(' Roof drain (commercial) 16.60
�� F� ffl L Sink/basin/lavatory 16.60
(t "} . 7 U' ' I �� // ' I rL ,) lS i71 � ! � � Tub/showcr /shower pen 16.60
E-mail: � -- , Q l0 Urinal 16.60
F CO RACTOR Fax: Water closet 16.60
\Business name: Water heater 16.60
t ' "Address: Other. •
✓ , City /State/ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) Fax: ( ) Residential backtlow minimum permit fee: $36.25
CB Lie.: Plumbin Lie, no.: Plan review (25% of permit fee)
Authorized sign `! -i r t// Slate surcharge (12% of permit fee)
_ / / / TOTAL PERMIT FEE 02 C)
Print name: 1 oft; G L+ ref l Date: 2:t ?ail This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
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