Permit CITY TIGARD PLUMBING PERMIT
Aron , DEVELOPMENT SERVICES PERMIT #: PLM2005 -00360
.J 11 DATE ISSUED: 8/9/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2S112CD -14400
SITE ADDRESS: 07937 SW CAROL ANN CT ZONING: R -12
SUBDIVISION: REBECCA MEADOWS LOT: 001 JURISDICTION: TIG
Project Description: Backflow device.
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
Owner: FEES
KEYSTONE DEVELOPMENT INC
PO BOX 476 Description Date Amount
LAKE OSWEGO, OR 97034 [PLUMB] Permit Fee 8/9/2005 $36.25
[TAX] 8% State Surcha 8/9/2005 $2.90
Phone : 503- 635 -4736 Total $39.15
Contractor:
NATURESCAPING
10950 S MAPLE GROVE RD
MOLALLA, OR 97038 REQUIRED ITEMS AND REPORTS
Phone : 503- 873 -8407
Reg #: PLM 7075
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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 or 1- 800 - 332 -2344.
Issued By: __ n ;//lb Permittee Signature: j� Nr1 Q�
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
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.
, Building Fixtures
Plumbing Permit Application FOR OF USE ONLY
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City of Tigard u ll i E C E II V E 0 Received P ermit No.:
13125 SW Hall Blvd., Tigard, OR 97223 Dat /By � 0-17"---11- . •
``I"'� �6 t-
Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 AUG O 9 2nr / ��� 1 , Date /By: Other Permit No.:
24- Hour Inspection Line: 503.639.4175 fil lr Date Ready/13y: a See Page 2 for
Internet: www.ci.tigard.or.us Notified/Method: -7 Supplemental Information
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. _ TYPE Oi WORKTIGARD FEE* SCHEDULE
uvit�ri a vi ioiviv For special ormationusechecklist.
[]"New construction ❑Demolition P I
Description I Qty. I Ea. I Total
❑ Addition /alteration/replacement ❑ Other: New 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: 7q37 5441674,doc. ,4 ,/ c.-7 Catch basin or area drain 16.60
' City /State /ZIP: -'77_ ,q Drywell, leach line, or trench drain 16.60
/a t. no.: Pro name: Footing drain (no. linear ft.: ) Page 2
Suite /bld
g p I , �e...,6 v tur✓ Manufactured home utilities 110.00
Cross street /directions to job site:
/''� Manholes 16.60
/dc°./°Tr/h! Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: h /:::: BC-GGA r ,i�"),i4�,5- I Lot no.: /„' 3 L/5' Water service (no. linear ft.: _) Page 2
I Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OE' WORK _ Backflow preven4er ) Page 2
Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
Drinking fountain 16.60
- :` PROPERTY: OWNER ° ❑ TENANT '' % Ejectors /sump 16.60
Name: 'SlOrs/ L2$1/ _2P, .% Expansion tank 16.60
Address: / gee?' 97 6. Fixture /sewer cap 16.60
City /State /ZIP: Floor drain/floor sink/hub 16.60
Phone: (13 ) 70 4 4-95 - 4.1!...3 - Fax: (j) Garbage disposal 16.60
Hose bib 16.60
.;`D APPLICANT . .: 0 'CONTACT,;PERSON. i ` ' . •
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: Sink /basin/lavatory 16.60
( ) Fax::( )
Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
• • . .• CONTRACTOR - • _ Water closet 16.60
' /< -TG
Business name: °'it SC .°, i / V�� Water heater 16.60
Address: h 41: 74' 'LF ei %i � Other:
Subtotal
City /State /ZIP: c' OR-. 4, 7& '3v
� Minimum permit fee: $72.50
Phone: (.5a3) 07g-- (r .i�j° 7 Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: 1 /:;?,;2 00 Plumbing Lic. no.: 70 •7 Plan review (25% of permit fee)
7# �,./1' State surcharge permit fee)
Authorized signature:
TOTAL AL PERMIT FEE
Print name: / Tf/ z .8E7 l Date: Q' - . 5 This permit application expires if a permit is not obtained within
N 180 days after it has been accepted as complete.
*Fee methodology set by Tri -County Building Industry Service Board.
is \Building\Perm its \PLMF-Perm itApp .doc 06/05 440- 4616T(10 /02 /COM/WEB)