Permit Iiii ,-- . , ..' If CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00036
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 02/17/2012
Parcel: 2S102AC01000
Jurisdiction: Tigard
Site address: 12575 SW MAIN ST
Project: Wei Li Acupuncture Subdivision: BURNHAM TRACT Lot: 1
Project Description: Installation of double check valve.
I
Contractor: DELTA PLUMBING INC Owner: LI, WEI
12205 SE 108TH AVE 11053 SW WASHINGTON ST
HAPPY VALLEY, OR 97086 PORTLAND, OR 97225
PHONE: 503 - 698 -7342 PHONE.
FAX:
FEES
Quantity Description Date Amount
I ea Backflow Preventer 02/17/2012 $31.27
Specifics: 1 12% State Surcharge - 02/17/2012 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 02/17/2012 $41.23
Type of Use COM 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 O/ Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if w.) is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to fo r e rules adopted by the Oregon
Utilit , o ification - ■ter. Th.: - rules are set forth in OAR 952 - 001 -0010 through OAR 952 -00 :0 • 0 Yo may obtain a co. of the rules
or .irect questions to OU b, calling 13.232.1987 or 1.800.332.2344.
issued By: / Perm Signature: 0 /
Call 503.639.4175 by 7:00 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.
Plumbing Permit Application
Site Utilities ������� "� - FOR OFFICE USE ONLY
City of Tigard FEB 1 7 2012 R : 6Z / 2 /' , ' Permit No.: e 'i/ g 'tom
o /a - 3 e,
lig - a 13125 SW Hall Blvd., Tigard, OR 97273 Plan Review
Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Other Permit No.:
Inspection Line: 503.639.4175 �ITr OF TIGARD Date/By:
T I G A K D B UILDING DIVISIO �I
Datei B Juris: la See Page 2 for
Internet: www.tigard- or.gov �{Voti Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑Demolition For special information use checklist
Description • . Ea. Total
0 Addition/alteration/replacement ❑ Other. New 1 - 2-family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
❑ 1- and 2- family dwelling [9 Commercial/industrial
SFR (2) bath 437.78
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: Catch basin or area drain 18.76
s� �7 ' S S ( Li /Y1�� l L. 5
� "���,�.� � � -7 � �
Drywell, leach line, or trench drain 18.76
City /State /ZIP: .
f cy /� 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: I Lot no.: Fixture or item:
Tax map /parcel no.: Backtlow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
3k 00e)// V Clothes washer 25.02
00e)t�e C. At E ^r r /4 octu // (G /jl ./ /)) fil')e Dishwasher 25.02
n/4 f1'6 Q /OPP16Iiy ('r7�j L wak,. Drinking fountain 25.02
)ICJ ne,r CU 1 1 C 11,66 k- 0 9 S 1 i,n icier S j .S kAA- t Ejectors/sump 25.02
CEt PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
c0 i./
Floor drain /floor sink/hub 25.02
Address: /R 78 DA" )1 Garbage disposal 25.02
City/State/ZIP::� i / vt . q/? 's Hose bib 25.02
Phone: K.ei 3) 5. . ..105Z Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name:
Roof 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
' 7 Water heater 37.52
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Business name: pi 7.z, - PL (/t/t4 1 /A/6---- /A/t!i
Water piping/DWV 56.29
Address: /2 2625 5 �(, Other 25.02
City /State /ZIP: t / A I •' % vu Subtotal
Phone: (9 ) • g ���, . Fax: ( - ) Minimum permit fee: $72.50 �2 .5
CCB Lic.: i Q g2 Plumbing Lic. no.: 05 Plan review (25% of permit fee) �
t 6 - State-surcharge (12% of permit fee) . ,70
Authorized signature: l e p� ( TOTAL PERMIT FEE O , 2 v
Print name: /S/w 70-7/' Date: 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.
l:\ Building \Permas\PLMU- PcnitApp.doc 10/01/09 440W616T(10/02/COM/WEB)