Permit 9
. CITY OF TIGARD PLUMBING PERMIT
"'! :` COMMUNITY DEVELOPMENT Permit #: PLM2009-00106
Date Issued: 05/04/2009
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 1S135DC00400
Jurisdiction: Tigard
Site address: 11795 SW GREENBURG RD
Subdivision: Lot: 0
Project: Black
Project Description: Replace 35' of sanitary sewer service.
Owner: FEES
GREENBURG LLC Quantity Description Date Amount
BY STEVEN & MELISSSA BLACK, PO BOX 1891 35 If Sewer Service 05/04/2009 $55.00
LAKE OSWEGO, OR 97035 1 12% State Surcharge - 05/04/2009 $8.70
PHONE: • Plumbing
18 ea Minimum Fee Adjustment 05/04/2009 $17.50
Contractor: - Plumbing
NORTHWEST PLUMBING & DRAIN
16630 SW WRIGHT ST
BEAVERTON, OR 97007
PHONE: 503 - 642 -9841
FAX:
Type of Use: COM
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 Notifn Center Thos- •s are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
Issu By: / k I , 1 Permittee Signature: 41111
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.
" 'lt nibing Permit Application
FOR OFFICE USE ONLY Q
1 111 q City of Tigard Received 5 41' o 9 / Permit No • ` (17 / 2el, QO /,0
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
_ Phone: 503.639.4171 Fax: 503.598.1960 Date/By Other Permit No •
TIGARD Inspection Line: 503.639.4175 Date Ready /By. Juris ® See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
,_ ,.. ;,,.... »�.. a...,..,::: �; . :.: p,;�,� ,. ,� b > °cad -.» � :�: . °. ..,...�. ...p,. sr he ' "�.�, s* ��-�..r. -MSU w. Ra�Y, pv :�.,: ;.
:,' z ; ' , . s :; „,,c, a t . I TY OF °WORK : t xi l ;
i k 1 , � ..r 'elgi FE S CHED ULE � . L
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
dition/alteratio replacemen ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
4 ..\. f;: .' , 1 CATEGORY OF COIVSTRU,CTION h x , I t w SFR (I) bath 249.20
❑ 1- and 2- family dwelling Wommercial /industrial SFR (2) bath 350.00
Li Accessory building I=I Multi-family SFR (3) bath 399.00
I] Master builder ❑Other: Each additional bath/kitchen 45.00
�� _ ∎ 4 Fire sprinkler ( sq. ft.) Page 2
: ' ; . JOB SITE INFORMA IO,,KD71 LOCATION I. „ Site utilities
Job site address: / 1773 Sr _,J 44,4144- 61 ) ) n bor Catch basin or area drain . 16.60
City /State /ZIP: i y- .1 v ' J Drywell, leach line, or trench drain 16.60
Suite/bldg./apt. no.: �/ I Project name: 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
Sanitary sewer (no. linear ft, 7,`) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
f ' ` D3CRI WO ' - "I
� �, i�..c � �:.�. , �.��,. � . . � ,�. , . .....� . .r FC Backflow preventer Page 2
r .
_o_r � .-- ,� { _ Q) Backwater valve 16.60
r Y.
^ / Clothes washer 16.60
� Dishwasher 16.60
, r Drinking fountain 16.60
❑ PROPERTY', OWNER- f : la TENANT ,-, t- v ,, ` y , •
. ,.. v f + t Ejectors /sump 16.60
, Name: /0-- js� / , Expansion tank 16.60
Address: �' Fixture /sewer cap 16.60
City /State /ZIP: Floor drain /floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60
�� A r Hose bib 16.60
"'; : sr�' 1, APPLICANT fi s y C O N TCT P.ER50 :. � 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
Sink/basin/lavatory 16.60
Phone:
( ) I Fax::( )
Tub /shower /shower pan 16.60
E -mail: Urinal 16.60
;^'"� 4 " . CO y ' t° fr , ,,..; Water closet 16.60
Business name: L7 T pt D l Water heater 16.60
\ q Address: SZA--f LA-I f; Other:
a City /State /ZIP: e" , i ��� ,�� ®�- ?of: 7 Subtotal
Minimum permit fee: $72.50 Sd
C\ Phone: s 3 ) f -iv..// Fax: ( ) Residential backflow minimum permit fee: $36.25 ZA •
CCB Lie.: tubing Lic. no.: p8 Plan review (25% of permit fee) _ - '
' 7 / /// State surcharge (12% of permit fee) ' . 70
Authorized signature!r' _- /
TOTAL PERMIT FEE g �a
Print name: '�.4-V e,0 A.r4T' eA/S Date: $ r / U g This permit application expires if a permit is not obtained within
1 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I: \Building\Permits\PLM- PermitApp doc 12/27/06 440- 4616T(10 /02 /COM/WEB)