Permit CITY TIGARD PLUMBING PERMIT
4 DEVELOPMENT SERVICES PERMIT #: P 28/200 -00069
�'` 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/28/2005
SITE ADDRESS: 11705 SW ANN ST PARCEL: 2S103BA 00116
SUBDIVISION: LERON HEIGHTS ZONING: R -4.5
BLOCK: LOT: 016 JURISDICTION: TIG
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: 1
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remarks: Installation of backflow device.
Owner: FEES
ERWERT, ROBERT E TRUSTEE Description Date Amount
11705 SW ANN ST
TIGARD, OR 97223 [PLUMB] Permit Fee 2/28/2005 $36.25
[TAX] 8% State Surchaq 2/28/2005 $2.90
Phone : Total $39.15
Contractor:
SIGNATURE LANDSCAPE
PO BOX 304 REQUIRED ITEMS AND REPORTS
TUALATIN, OR 97062
Phone : 503- 673 -0252
Reg #: PLM 6195LCB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law
requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by
calling (503) 246 -6699.
Issued By: �,j tea Permittee Signature: J 4
Call 503 639 -4175 by 7 :00 P.M. for an inspection the ne day.
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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.
I CO Plumbing Permit " , ` ;` FoR (W Ica. USE. ONLY ,
R
City of Tigard Received
^ U� Permit N67 ^'` �i
13125 SW Hall Blvd., Tigard, OR 9722 c, a os DateBy 6 5 l) i� _
Plan Review 1.� �!N } t� )
�+
Phone: 503.639.4171 Fax: 503.598.1 WO Ai # ryP ° " I ;\ Date/By: Other Permit No.:
24- Hour Inspection Line: 503.639.417 �1 t) - i 1 Date ReadyBy: orris. ®See Page 2 for
Internet: www.ci.tigard.or.us G1 -vs/ O ?-fa 1v `t iO ' Notified/Method: �
U supplemental lnformetion
TwIteko FEE* SCHEDULE
❑ New construction ❑ Demolition _ For special information use checklist
/� Description . 1 Qty. I Ea. Total
❑ Addition/alteration/replacement .Other: New w 1 - 2 - family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: / ( 767 51,0 Alm 56 Catch basin or area drain 16.60
City/State /ZIP: 7 qC
` am„ j OR_ te-?ZZ - Drywell, leach line, or trench drain 16.60
-
Suite/bldg. /apt. no.: 0 1 Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
t 2(e pi, / a (il c A It Rain drain connector I 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) 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
�/ 3'(..2 -
t esrdeAkt a e f k -Lbw tlt,1<Q jfeE" «^ 6,10 Backwater valve 16.60
e,4 . (i ( ' ( ,&2 A t Clothes washer 16.60
Dishwasher 16.60
J'ROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors/sump 16.60
Name: g6 6er �'- I"f( +t. Expansion tank 16.60
Address: l I-7 5-6) g ._ Fixture/sewer cap 16.60
City/State /ZIP: -r 0 ,4 O __ 97 2.21,7 Floor drain/floor sink/hub 16.60
Phone: (5b3)-- 5 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: , Water heater 16.60
Sr of a f ape_ �,rr.� -c��r a ®� C /_iE
Address: r p Li) ,C► e. 5,6y- / Other
City /State /ZIP: -7-u a ca f A a/ Q76r; Z
Subtotal Z ,
Minimum permit fee: $72.50
Phone: ( ) 73 -62 6 Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: 6 1 p tia ( Plumbing Lic. no.:
Plan review (25% of permit fee)
Authorized signsignature: /� State surcharge (8% of permit fee) 2 q
<,.7 �Sw TOTAL PERMIT FEE 37.. S .--
Print name: Date: 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 Building Industry Service Board.