Permit CI TY OF TIGARD PLUMBING PERMIT
1 DEVELOPMENT SERVICES PERMIT #: PLM2005 - 00166
Al 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 4/27/2005
PARCEL: 2S 109DA -06500
SITE ADDRESS: 14991 SW GREENFIELD DR ZONING: R -7
SUBDIVISION: SUMMIT RIDGE LOT: 042 JURISDICTION: TIG
Project Description: Install residential backflow prevention device for irrigation system.
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
DON MORISSETTE COMMUNITIES LLC Description Date Amount
4230 GALEWOOD ST # 100
LAKE OSWEGO, OR 97035 [PLUMB] Permit Fee 4/27/2005 $36.25
[TAX] 8% State Surcharl 4/27/2005 $2.90
Phone : 503- 387 -7538 Total $39.15
Contractor:
LANDSCAPE OREGON, INC.
12200 SW MYSLON RD. REQUIRED ITEMS AND REPORTS
TUALATIN, OR 97066 2
Phone : 503- 692 -5945
Reg #: LIC 7804
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes
and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is
not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law
requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-00014; i • ough OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by
calling : 46661
y: Permittee Signatur
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
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(CI of T(City an- +I Received
13125 SW Hall Blvd:', Tigard, OR 97233 X1005
Phone: 503.639.4171 Fax: 5jl Pla R . 'y�0 AM Permit No..
, 1960 // y /p „ a t` Plan Review
p `d 9$p - t .� .� f� ' •t. Date/By: Other Permit No.:
24 Hour Inspection Line: 504 9,41 5 �"� y tl t �,; Alr
f f� ,,,�.;� Date Ready/By: • El See Page 2 for
Internet: www.ci.tigard.or.us `' 016 C� ^11 Notiled/Method: / !a Supplemental Information
1 r �`C 1 ar FEE" SCHEDULE
New construction v
t jt , ` ❑ Demolition For special information use checklist.
(� m�sL � i Description I Qty. I Ea. Total
❑ Addition /alteration/rplact went El Other: New I- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION I
SFR (I) bath 249.20
- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
CI Accessory building ❑ Multi - family ^ SFR (3) bath 399.00
CI Master builder Each additional bath/kitchen 45.00 •
❑ Other: Fire sprinkler ( sq. ft.) Page 2
. . 3013:' SITE INFORMATION AND' LOCATION Site utilities
Job site address: / y qq / S`t �, e.-7 6 cfes�, f) rI ae Catch basin or area drain 16.60
City /State/ZIP: Ti G 4120 -L, r> Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: Project name:SL Jnf It kiit 1 , 4 Footing drain (no. linear ft.: ) Page 2
Cross street/directions to job site:
` Manufactured home utilities 110.00
Manholes 16.60
t.0 (3C'. C' '1- acrid i2•(' _ Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service no. linear ft.:
Subdivision: S L( yyt yyt - to � (e f .� Lot no.: 4 -1 1 ( ) Page 2
Tax map/parcel no.: fei 5-S- Fixture or item
Absorption valve 16,60
l7ESC12IETION OF WORK Backflow preventer Page 2 ,2 7. SS
6.......a44 • i ,, 7'- 0y l✓''>'1 ht r f l a ;,l y / (';'' , Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
' 11, : ❑ TENAN7 Dttnkingfountain 16.60
- Ejectors /sump 16.60
Name: ) {/ - )/JYI Ss t= f.-A f*1 >vS Expansion tank 16.60
Address: z--/Q 3 0 S Liu _) 'C ( e. O CSC. Fixture /sewer cap 16.60
City /StateeZIP:L.CC -!fie 0 S w t)�) OA_ 70.3 5 Floor drain/floor sinlc/hub 16.60
Phone: (. ) ! Fax: ( ) Garbage disposal 16.60 1
Hose bib 16.60 i
AI PLK :AN1' _ CQPiTiA.CI".PERSON •
n r Ice maker 16.60
Business name:
l�J� , , a .a 1_,t'�, �i Or ef 0 �� Z I
1 0 � / Interceptor /grease trap 16.60
Contact name: 1 / t ,:s �L• TK7tC Medical gas (value: $ ) Page 2
Address: . - ; \ .-C , 0 .,f,0 1 ,, l inn L ' g , 9 Primer 16.60
Cit /State/ZIP: Vl U2 , -1 '7 76,4"o a,__ Roof drain (commercial) 16.60
1 ' ‘.-/,_ ,} , . Sink/basin/lavatory 16.60
Phone:
(56 3) (G't -�j 7 (i5 Fax : : ($3) g am; - C 7�'-',� Tub /shower /shower pan 16.60
E -mail:
Urinal 16.60
. CONTRACTOR Water closet 16.60
rne: -r•• .^ - -^ - `..
Business Wa
�, f ) 6 _s(.61p.6, f z - -917 -1 �,/) C, Water heater 16.60
Address: / •'� DD �.I..J in S- is / n"l�A y , Other:
City /State/ZIP: 4te r '4 'joie_ Subtotal
'
Minimum permit fee: $72.50
Phone: (.3) tgeo# -' S Fax: ( 3) (G 9 . -7(08- 0 Residential bacicflow minimum permit Fee: $36.25 4' S
CCB Lie.: 7 >U 1-21 Plumbing Lic. no.: Plan review (25% of permit fee)
7 0 State surcharge (8% of permit fee) 2 31.,. 31.,. ` 'l D
Authorized s ignyt�'' /
c ✓ -� ' �' �' / ?' // TOTAL PERMIT FEE 3 / S •
Print name' // en ` S.,,;"1 D ab' ,,( , 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.
i \ Building \Pcrrnus\PLMP- PcrmitApp.doc 12/03 440-4616T(20 /02/COM/WEB)
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