Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00022
T.fGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/01/2012
Parcel: 1 S134CB00600
Jurisdiction: Tigard
Site address: 12215 SW SUMMER ST
Project: ANDERSEN Subdivision: SUMMER HILLS PARK Lot: 4
Project Description: Replacing tub /shower.
Contractor: RAYBORN'S PLUMBING INC Owner: ANDERSEN, CHRISTOPHER D &
19990 SW CIPOLE RD TERESA S
TUALATIN, OR 97062 12215 SW SUMMER ST
TIGARD, OR 97223
PHONE: 503 - 692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
1 ea Tub /Shower /Shower Pan 02/01/2012 $12.51
Specifics: 1 12% State Surcharge - 02/01/2012 $8.70
Plumbing
Type of Use: SF 60 ea Minimum Fee Adjustment - 02/01/2012 $59.99
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 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 503.63�� 7:00 a.m. for the-next-available-inspection-date. _ _ - —
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.
• ..503 691 2328 Rayborns Plumbing 01:58:53 p.m. 01 -31 -2012 1 /2
Plumbing Permit Applicati t Ec
Building Fixtures ��� Ft 1k UP_hic ...._I SE 0 \I.) _
d
14 , • City of Tigard n Received Permit No
13125 SW Hall Blvd., Tigard, OR 97223 N 3 1 2012 Date /By: I 31 lA �/ ,Lin 9`6 Lk ,k
Plan Review O ther Permit No.:
Phone: 503.639.4171 Fax: 503.598.1960 Date /By: _
T1 l . 1 it I inspection Line: 503.639.4175 CITY OF TIG fi D Dale Ready /By: r is: See Page 2 for
Internet: www.tigard - or.gov CliS Notified/Method: J , Supplemental Information
Bull ut`JIrIG
TYPE OF WORK FEE* SCHEDULE
❑ - r ye construction ❑ Demolition For special information use checklist
Description f Qty, I Ea. I Total ,
Addition/alteration/replacement ❑ Other: New I- 2- family dwellings (includes 100 R. for each utility connection) _
CATEGORY OF CONSTRUCTION. SFR (1) bath 312.70 ry
12'nd 2- family dwelling CI Commercial /industrial SFR (2) bath 437.78
( l- a SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: ) D....15 5 L) 5 0 w( ,,k, e. r J t Catch basin or area drain 18.76
�;' Drywell, leach line, or trench drain 18.76
City /State /ZIP: f t Ud Q t r (-( a
' Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: _) Page 2
Storm sewer (no. linear ft,: _) Page 2
Water service (no. linear ft.: _) Page 2
Subdivision: 1 Lot no.: Fixture or item:
Tax map /parcel no.: Backtlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
R e 0\/LC C- 1\ ) / -' d ∎-c' e t 5 `/l.', ')` Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER l ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: Garbage disposal 25.02
City /State /ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
p (� Medical gas (value: $ _) Page 2
Business name: f t r K S I t U tM �o ` � � -
Y Primer 12.51
Contact name: A) a:4 _ fl /A.Ue l ( �
n ' e.l Roof drain (commercial) 12.51
Q
Address: 1 1 c( k 0 S e, 1 C Cg
. i . Sink/basin/lavatory 25.02
i -
City/State/ZIP: ,1,1 0 r 4700 ? Solar units (potable water) 62.54
Phone: ({;D3) ‘q2_ t/13ef Fax: :03 ) (qf -.23.2g Tub /shower /shower pan / 12.51
Urinal 25.02
E- mail: /laf CU Pvt 5 . Ca f
Water closet 25.02
CONTRACTOR
Water heater 37.52
/
Business name: ''/ a f 14 S pt v Wv,lo i A \ t . 0 Water piping DWV 56.29
Address: , c-{ 10 s 1. . 1 G, ee C Other: 25.02
City /State /ZIP' { ,,,,... r ek '10 6 ' Subtotal
Phone: (5o) ) 6 9a _ 1 3 Fax: (Sd3) 6q/ _ ;3 e Minimum permit fee: $72.50 7,2 ,,
CCB Lic.: g Ls �,. Plumbin• 'c. no.: yq -,��P� Plan review (25% of permit fee)
%� State surcharge (12% of permit fee) 5-- D
Authorized signature: �� Vii, /�- TOTAL PERMIT FEE - 7.d
L Date: / This permit application expires if a permit is not obtalne th 80 day
Print name:
/l/t� - � Het \/l UL � /.2 after it has been accepted as complete.
"Fee methodology set by Tri- County Building Industry Service Board.
P- Building Permits‘PLMU- PermitApp.doe 10.0609 410-- 516T(10,02.COMIWEB)