Permit CITY OF TIGARD PLUMBING PERMIT
''� : ' COMMUNITY DEVELOPMENT Permit u PLM2011 -00317
Date Issued 10/25/2011
TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 718 2439 parcel 25111 CB01706
Jurisdiction Tigard
Site address 10305 SW HOODVIEW DR
Project CIROTSKI Subdivision HOOD VIEW Lot 5, PLUS
Project Description 100 ft of sanitary sewer Reimbursement district fees paid 10/25/11
Contractor ALL WAYS EXCAVATING USA LLC Owner CIROTSKI, LAWRENCE L AND LAURA L
PO BOX 238 10305 SW HOODVIEW DR
HUBBARD, OR 97032 TIGARD, OR 97224
PHONE 503 -982 -3544 PHONE
FAX 503 - 982 -3654
FEES
Quantity Descnption Date Amount
100 If Sewer Service 10/25/2011 $62 54
Specifics 1 12% State Surcharge - 10/25/2011 $8 70
Plumbing
Type of Use SF 10 ea Minimum Fee Adjustment - 10/25/2011 $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 -0091 You may ob - r a copy of the rules
or direct questions to OUNC by calling 503 232 1987 or 1 800 332 2344
.i
Issued By
• Mee Signature ar
Call i /- 175 by 7 00 a m for the next available in • :ate
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
Plumbing Permit Application �
,�
Building Fixtures a`,, v. j Foa .
OFLIC ,ASE ONL_l 2" x .' yid'
'
Received l u 5--hi n Permit No P1Mae /i•- '(Y)3/ 7
i City of Tigard V 13125 SW Flail Blvd, Tigard, OR �� Date/By Date/By 'Tian Review
Phone 503 718 2439 Fax 503 5 60 p 11 Other re<,nn No e
TI Inspection Line 503 639 4175 `_ ,A5.\\ Date Ready /By lun< ® See Page 2 for
Internet www tigard -or gov KQ�rsV w �'• onfiediMethod •�/ Supplemental Information
;, 1 WORK (.y� QsA ' 't%�V ' . I ; ;d ;FEE* "SCHEDULE, • ;,i'."
❑ New construction ❑ Demo. %nee iV *1 For, special information use checklist
` Description I Qty I Ea I 1otal
❑ Addition/alteration /replacement ❑ Ota <_ New 1- 2- family dwellings (includes 100 ft for each utility connection)
¢' ' : • x • . em u CATCCORY,OFdCONSTRU � N +7 ' �" �L -3 u 1 SFR 1 bath 312 70
»^ _ �
+ (' � ,�V' SFR (2) bath 437 78
BI- and 2- family dwelling ❑ CommerctaUit ttrla l ��,� .
.(V e. `J' SFR (3) bath 500 -32
❑ Accessory building ❑ Multi- family t.. ^
Each additional bath/kitchen 25 02
❑ Master builder ❑ Other 0 \S`\ d _ Fire sprinkler ( sq ft) Page 2
• JOB SITE INFORMA PION' -AND LOCATION . ,i Site utilities:
Job site address ) obi) SA) �yr!7il / 4rs) Catch basin or area drain 18 76
City /State /ZIP ) G 1 ' ` ^� /� q Drywell, leach line, or trench drain l8 76
� /`1- t Footing drain (no linear ft _) Page 2
Suue / bldg /apt -no.. Project name ( i ' KI Manufactured home utilities 5003
Cross street/directions to job site l Manholes 18 76
Rain drain connector (,,, 18 76
Sanitary sewer (no linear ft ,g,) I Page 2 ( )„,..5
Storm sewer (no linear ft ) Page 2
Water service (no linear ft ) Page 2
Subdivision I Lot no Fixture or item:
Tax map /parcel no
Backflow preventer 31 27
it DESCRIPTION OF WORK " , 'I Backwater valve 1251
1 i Clothes washer 25 02
t 1 / I
- r L _ • Dishwasher 2502
1 I Dnnking lountarn 25 02
Ejectors /sump 25 02
VF Ir ROPEI'Y 'OWNER•' , ' ❑ TENANT � Expansion tank 12 51
Name 1 A v (' rr Fixture/sewer cap 2502
* Floor loor /sews drain/floor sink /hub 25 02
Address 104 e'n ��
�0 Garbage disposal 25 02
City /State /ZIP ll A 1? ?Wirt
17 l2Q4 i Hose bib 25 02
•
Phone (� "T r.S ( (0� Fax ( ) Ice maker 12 51
❑ APPLICANT ❑ . CONTACT PERSON r Interteptor/grease trap 25 02
Business name Medical gas (value $ _) Page 2
Primer 12 51
Contact name
Root drain (commercial) 12 51
Address Sink/basin/lavatory 25 02
City /State/ZIP Solar units (potable water) 62 54
Phone ( ) Fax ( ) Tub /shower /shower pan 12 51
E-mail Urinal 25 02
- _ Water closet 25 02
CONTRACTOR
/ Water heater 37 52
Business name h la". ' •/ .11/ AS Water pipin WV 5629
Sri i r
Address Other 25.02
City /State /ZIP tigmamayil `) Subtotal 6 2. s—j 1
Phone ( - ' 1 ) + Fax ( Al� or- Minimum permit fee $72 50
CCB Lie • ie Plan review (25% of permit fee)
`/�`.� <itllri/IL�tf A State surcharge (12% ofpemnt fee) ,, 3 -'-
Authorized s azure k r / /' C (( / -2/, pi TOTAI PERMIT FEE v
l C Pant name e ) I C i,- {',�ia / l- i tC ZED l his permit application expires if a permit u m
mit not obtained within 85 days
4 after it has been accepted as complete.
`Fee methodology vet by To- County Building Indnmy Service Board
IIBu,m,nevenn,capLMU- Permanppdoe ioioimv 410- 4616u10ro2(COMnvr3) fi 11 / 2 /71 <
/0 (ol/ A ( , .
F3
Commrrwrrmm Devellopment
S enennbursement D stnct Payment Worksheet
T IGAMile
Planning /Engrneeran to corgi ➢etc:
Site Address j `O 3O 5 SG-) Tilc4 VIA b
Parcel No _2_54i4C—J3
cD
Reimbursement D3stnct No Amount Due $ (n O 00
Date / �� 1/ By �
Note Amount due is as of date shown above
Deferred Accounts:
Name fti..� f 2 v.C< ± A,v.A.G- C 1 fp4
Phone Number
Legal I L 4, L-- 5 251 1) Cg f isL
Amount paid $
tO
Remaining to be paid, deferred amount $ L 9 ✓ /
Building Division to corn lete:
Reunbursement amount paid $ 6
Received by - _ /0�15Sl
Return completed worksheet with copy of receipt to planning /enguveermg permit technician
Plannin /Engrneenng to complete:
Enter "paid" parcel tag
Enter "deferral" parcel tag, if applicable
Route copy of receipt and parcel information pnnmout to Finance Department
1 ACURPL N \Masers \ReimourseWorksheet doc 323/0'/
( P)--M a `' 11 - ° °3 i7
0305 3Uu HowITL0
SALES RECEIPT
JONES AGGREGATES INC.
WE RESERVE THE RIGHT TO ADD A 550.00 PMB 55
FEE TO ALL RETURNED CHECKS. A LIEN
WIIA. ALSO BE PLACED ON JOB SITE, IF 13023 NE HWY 99, SUITE 7
CHECK IS RETURNED NSF. VANCOUVER, WA 98686
WA (360) 834 -1282 FAX (360) 817 -9249 OR (503) 777 -3753 TOLL FREE: 1-877-887-0363
DATE:
SOLD TO: CONTACT PERSON:
ADDRESS
JOB NAME: JOB P.O. #: MATERIAL P.O. #:
DELIVERY ADDRESS
MATERIAL TONS YARDS LOADS PRICE PER SUB TOTAL
TON/VD/LID
3A
FORM OF PAYMENT
C.O.D. ❑ CK.#
C7 SUB TOTAL
Q CUSTOMER BILUNG
❑ CREDIT CARD # _ Exp. Date SALES TAX
CREDIT CARD HOLDER SIGNATURE REQUIRED CODE NUMBER TOTAL DUE
Customer signature required verifying and acknowledging receipt of above stated materials, delivery address, and of the
Customer Signature:
Two *vacs DUE ao mama 10a, a Fa&OVAW mount LENS • DAN Jams AGGREGATES INC. 'some ayes Nm10E of ITS REsenva1ow OF THE nf01T To ASSERT /WV AND ALL LIENS AONNSr Pune+u es av nano ;moss AMINO uNDE0
All AFFousME FEOEwu.. STATE, on LOCAL LAWS IN THE EVENT TIE WINCES STATED IN THIS AGREEMENT ME NOT WOO WHEN o,s.
1030c
O 3 0 5“-) i4o0DV-741j
LI a oil- 0v -5 17
t ot
Carl's Septic Tank Cleaning, Inc.
Mailing Address: 4742 Liberty Rd. S. #147 Salem, Oregon 97302
Todd Zelmer (503) 910 -6329
To: /3( e4.) aw C . Work Doe (('") —1 If
—
kump . OS 60 . gallon tank S Total Doe S
Power Snake Line S
0 Locate and/or dig up tank S Pd#
OOther
Balance Due S
Cormoie(ts: �� r � C V S � .4 e•� bS � - - Vt, I-41
THIS IS YOUR DILL AND RlECLItT. Payment is due at of service.
finance pitirp of 2.5% per month on all balances unpaid after 30 days.