Permit • • • CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00033
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/14/2012
Parcel: 1 S126DC00901
Jurisdiction: Tigard
Site address: 9640 SW GREENBURG RD
Project: Gethsemane Lutheran Church - Pastor's House Subdivision: LEHMANN ACRE TRACT Lot: 5
Project Description: Replace shower pan, vlave, lay & water closet in pastor's house.
Contractor: RAYBORN'S PLUMBING INC Owner: GETHSEMANE EVANGELICAL
19990 SW CIPOLE RD LUTHERAN CHURCH
TUALATIN, OR 97062 9640 SW GREENBURG RD
PORTLAND, OR 97223
PHONE: 503 - 692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
1 ea Lavatories 02/14/2012 $25.02
Specifics: 1 ea Tub /Shower /Shower Pan 02/14/2012 $12.51
1 ea Water Closet 02/14/2012 $25.02
Type of Use: SF 1 12% State Surcharge - 02/14/2012 $8.70
Class of Work: ALT Plumbing
Type of Const: 10 ea Minimum Fee Adjustment - 02/14/2012 $9.95
Plumbing
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
issuan =, • i wo suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Util Notification Center. hose rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
o direct questions to OUNC by ng 503.232.1987 or 1.800.332.2344.
ssued By: /`� / Permittee Sign.
or -d utL
Call 503.639. 4175 - by 7:00 a.m. fog the next available inspe ion 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 03:50:23 p.m,. 02 -13 -2012 1 /2
03 691 2328 Rayborns Plumbing
Plumbing Permit Applicatio9 1 o
Building Fixtures ri►it Ol.FlC l•: t SI.: (►\I.'I
City of Tigard FEB 4 20 Received Argge� _
IIR 13125 SW Hall Blvd., Tigard, OR 97223 Date,ay: r PermitNo.: 4116 42 ^t70 3��
1 Phone: 503.639.4171 Fax: 503.59801,6 OF TIGA D Plan Review Other Permit No.:
Ins action Line: 503.639.4175 rt Date/By'
TI <.i:1K1� p BUI! DING D1ViSION DateReady /By: Avis: I RI See Page 2 for
Internet: www.tigard or.gov Notified Method: J
Supplemental information
TYPE OF WORK
FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
fit Description I Total
Other: Addition /alteration/replacement ❑ Oth ! Qty. I
New I- 2- family dwellings (includes 100 ft. for each utility connection)
111 1 . 1111.1..- CATE ' ' OF CONSTRUCTION ' SFR (l) bath 312.70
Ikr I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath
437.78
CD Accessory buildin: SFR (3) bath 500.32
r ❑ Multi- family
❑ Master builder Each additional bathikitchen 25.02
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION g
Site utilities:
Job site address: fig D C 6Aeeu f Catch basin or area drain 18.76
City/State/ZIP: ' ► ` /�h L l p tit Drywell, leach line, or trench drain 18.76 J
1 Footing drain (no, linear ft.: _) Page 2
Project Suite/bldg. /apt. no.: Proect namam e:
. .r• L . .. c / Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
t M• �j.1e , #� Rain drain connector 18.76
6 ,s-s- L+ / Sanitary sewer (no. linear ft.: _) Page 2
�> al Storm sewer (no. linear ft.: ,) Page 2
Water service (no. linear ft.: �) Page 2
Subdivision: Lot no.:
Fixture or Item:
Tax map /parcel no.: Backtlow preventer 31.27
DESCRIPTION OF WORI'j Backwater valve 12.51
1 �, a 10•! + Clothes washer 25.02
• - • Dishwasher
25.02
'-`"- _ Drinking fountain 25.02
Ejectors/sump 25.02
IXI PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: 6 + . C N /' l, , - _ _ / Fixture/sewer cap 25.02
Address: l ° / b i !� / �� 1 �l�/ +C-44.
Floor drain/floorsink/hub 25.02 A
City /State /ZIP: r' c, ,, • . tT a` Q , (� Garbage disposal 25.02
�4 e 'f/L� Hose bib 25.02
Phone: ( ) y Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grarse trap 25.02
Business name: Medical gas (value: $ _) Page 2 r
Contact name: Primer 12.51
Address:
Roof drain (commercial) 12.51
Sink/basin/lavatory 25.02 2S-11 1
City/State/ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tubishower/shower pan i 12.51 ig S(
E -mail: Urinal 25.02
CONTRA TOR
Water closet ! 25.02 Z S O1
Business name: t i L
Water heater 37.52
( b ' ∎ --. V • ) Waterpiping/DWV 56.29
rallelW
Address:
t t • i r
Other: s 25.02
City/State /ZIP: T Ott -9 /
CJ /L- 9 Oa r A
Subtotal t (2
Phone: 3-03 3 i G /. Q F. x: (s -z) 3) IS 9/-02307t? Minimum permit fee: $72.50 7 Z. °
CCB Lic.: ? es.-.. A mbing Li.. no.:3 -. .g6� Plan review (25 %ofprtmit fee)
/ II � � or
Authorized signature: State surcharge T (12% L permit T F l 41
f T!
d. -- - TOTAL PERMITFEE g ��
�� J A rl f 1 / A Date � This permit application mires if a permit is not obtained within ISO days di T after it has been accepted as complete.
•Fce methodology set by Tri- County Building Industry Service Board.
L Building Permits PLMU.PermitApp, 10.01:09 440 -t6 I6T(10 WEB)