Permit „ CITY OF TIGARD PLUMBING PERMIT
'1' COMMUNITY DEVELOPMENT Permit #: PLM2009 -00090
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/15/2009
Parcel: 1S134DB12700
Jurisdiction: TIGARD
Site address: 11294 SW ELLSON LN
Subdivision: Lot: 0
Project: Berg
Project Description: Backflow for irrigation.
Owner: FEES
BERG, DAVID L & Quantity Description Date Amount
BERG, KATHLEEN M, 11294 SW ELLSON LN 1 ea Backflow Prevention - RES 04/15/2009 $27.55
TIGARD, OR 97223 1 12% State Surcharge - 04/15/2009 $4.35
PHONE:
Plumbing
9 ea Minimum Fee Adjustment 04/15/2009 $8.70
Contractor: _ Plumbing
WEST HILLS PLUMBING
2925 NE REDWOOD DRIVE
MCMINNVILLE, OR 97128
PHONE: 503 - 648 -7574
FAX: 503 - 474 -9031
Type of Use: SF
Class of Work: NEW Type of Const:
Occupancy Grp:
Stories:
Total $40.60
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuanc k is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utili Notification Ce'n r. Tho e rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Is ed By: /n JA.A Permittee Signature: `
Call 503.639.4175 by 7:00 a.m. for an inspection that bu mess day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
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Plumbin;" Permit Applicatioe , C
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CBI City of Tigard o �� ll ter.! Mrib' O
Rail Blvd.. Ti ard.OR 9 Plae Review A e
w 13125 SW K g O Other Permit No.: � 1 ,� , 11 9
ii,. Phone: 503.639,471 Fax 503.598.;$ _. 9 20 J Date�BY
',cc-6(. Line: 503.639.4175 }fir 1� Mee Reedyl8y' c 6d See Nee 2 for
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Internet: ww.tig87d -or.gov Notined:Method: rt Sepptemerbl Inrarmatieo
,rte OPWO>i P,�(�OtTIGtPD • sc J E
i>11 ITaltfe�tfit St 1 Per epode! inibnn�ne use checklist.
�Fcsv constntcrion Dese . L21_1... Ea Total
. ❑ Addition /alteration /replacement ❑ Other: New 1,- lenity dwellings (includes 100 ft, for each utility connection)
CAT GORY OP Coi <il^ 1r11ON $FR (t) bade 249.20
1 - and 2- family dwelling ❑ Cent nercialfind tstrial SFR ( bath _ 350.00
SFR (3) bath 399.00
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 45.00
❑ Master builder ❑O ther: Fire sprinkler (_,_ sq. ft) J [ Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address P ( q y S 4 \ ..so ,A t--/ Catch basin or area drain 16.60
City/State/ZiP: .-1-‘ c <� . - > 1/ ' ' - 7 • Z-- 3 Drywell, leach line, or trench drain 16.60
Punting drain (no. linear It: _J Page 2
[
SuitrJbidg. /apt. no.: Project name: G r,,,...+,+,,,, , Msnufaccmcdhome utilities 110.00
Cress street/directions to job site: _ Manholes 16.60 _
G 6i I ( 4 1 t-.) / )r \- t) 6 -- -& 1 Rain drain connector 16.60
. Sanitary sewer ( n o. linear R: ___ _) Page 2
Storm sewer (no. linear ft.: ) Page 2
` tot nn.: Water service (no. linear ft.: _,,,_) _ Page 2
Subdivision Fixture or item
Tax map/parcel no.: Absouptionvalve 16.60
DESCRIPTION OF WORK 9ackflow prcvcmer 4 pac 2
L_ CA i-ti. A S Col) Q C. 1' l v.. `L- t e 5 ^ Backwater valve 16.60
Clothes washer 16.60
W Dishwasher 16.60
Drinking fountain 16.60
v
RO)1ERTY OWNER ❑ TENS Pjcc4rry /imp 16.60
em
i Ne: V Gt {- L b (-11-9 Expansion tank 16,60
Address: it 2- C Li ` jc,,} L L 50 (l) L- Ai Fixture/sewer cap 16.60 .
City/Stale /ZIP: c. t v'. t; / D /?__ i' 2 2 3 Floor drain/floor 3inkilmh 16.60
16.60
Phone: (7oj) 1 U S-- 3 6 Fax: ( ) Garbage disposal
_ 16.60
APPLICANT El CONTACT p oN Hose b ib -
,! / r) lee maker 16.60
Business name: 44 -aO 15 C.- ( l C r r 1( C-1 Interceptor /guest trap 16.60
Contact name: �� (� e‘,.. t� Medical gas (value: b) Page 2
i� /
Address: + Prinicr 16.60
22 v (� *� 1 r1 'J� C
City /Strict /P: T t e, 9 ;,, c* d r'l.- 9" ? 2 Z 3 Roof drain (commercial) 1 6.60
Sink/baaiMavatery 16.60
Phone: 1'75L y) 7 cc , e - 3 G Sr ` Fax:: ( ) Tub/shower /shower pan 16.60
E-mail: iJrinal 16.60
CONTRACTOR • II �j Water dosal 16.60 l
Business name: W L 3 I- (4 , ! (S 1, /u Jz f , ma:
Water heater 16.60
nh 1�
AdAddress: Ly.-�1 Z - . j I u 12-....S1 i- ,t5oc) r , b 2
Ci rStabe/Z3?: 1 6 i _ Subtotal
V11 C HA 1 ►'l i 1 U + i - ( l 2 - Minimum permit fee: 572.50
Trhane: ( j 3/q- c 3 4 1 ((.5-°3) 4 7 4( - 20'3 l ,� ' 2 C
Fax: R 6etekflovv minimum permit fee: 536.25
Plan review (25% of permit fee)
eeB [ i (j ? I Plumbing 1 ie. no. 3 •• 27 3 F State surcharge (12% of permit fee) it. 7 9 5
Authorir,ed signature: TOTAL PERMIT FEE
--''�� TO 1.4 D. 60.
Print name: �� j) ' , { D ate: L( - ..6 cf 7 T4lr permit application empires if a permit is not nhblined within
"` "� / 180 days after it has been accepted as complete.
r ( Fee methodology set by Tri- County Building industry Service Board.
TA Iluildinp4rermialPL.M•PtrmitApp A. 12/27106 I e0.46 .16T(101611CO?MK'1$)