Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00117
T I GA R D. 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/14/2012
Parcel: 2S110BB05500
Jurisdiction: Tigard
Site address: 14210 SW 121ST AVE
Project: Elliott Subdivision: ARLINGTON RIDGE Lot: 32
Project Description: New shower pan, toilet and 2 sinks
Contractor: M B PLUMBING Owner: ELLIOTT, RICH & BRENDA
7112 NE 65TH PLACE 14210 SW 121ST AVE
VANCOUVER, WA 98661 TIGARD, OR 97224
PHONE: 360 - 608 -9521 PHONE:
FAX: 360 - 696 -3330
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FEES
Quantity Description Date Amount
2 ea Sink 05/14/2012 $50.04
Specifics: 1 ea Tub /Shower /Shower Pan 05/14/2012 $12.51
1 ea Water Closet 05/14/2012 $25.02
Type of Use: SF 1 12% State Surcharge - 05/14/2012 $10.51
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $98.08
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: DILL A.r /Lie4-77z/S.
Call 503.639.4175 by 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.
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05/11/2012 15:12 5032318805 SELLWOOD CO. #5176 P.001 /002
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Plumbing Permit Apnlicatio
Building Fixtures F o k OFF 1 ( : E: I. ,F. i 1, l.,
City of Tigard MAY 1 4 2012 Received ) 12-, Permii)141.14 aol.),- 00417
74 13125 SW Hall Blvd., Tigard, OR 97223 Plans Review
Phone: 503.7182439 Fax 503.598.1 OF TIGA �D , _ , :: Other Pamir No.:
� Inspection Line: 503.639.4175
tic . A -: i V ISIONl Dar, ResdY Y y ps A See Page 2 for
Internet: www.tigardor.gov BUILDING �I ° Noti6ed/Me16od "1l 3 S ® e vt�ementa � tnfo
T PE OF. WORK .... r: FEES •SCHEDilI .. .
❑ New construction ` ❑ Demolition For special infonrudion use d
Description I Qty. I Ea. I Total
'Addition/alteration/replacement ❑ Other New 1- 2- family dwellings (includes 100 ft. for each utility connection)
. •CATEGORY :OP CO . : . ; . SFR (1) bath . 312.70
Igf- and 2- family dwelling ❑ Commercialllndustrrial SFR (2) bath 437.78 •
CI Accessory building SFR (3) bath 500.32
❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other. Fire sprinkler C sq. ft) Page 2
JOB SITE. INFORMATION AND LOCATION " Site utilities:
Job site address: 1 1 L{ 2, I, [ 0 kA) t z l S- A ve Catch basin or area drain 18.76
CCity/State/71P: `r l G �+ 1 T 0 f� a "] 22 14 Footing leach line, or trench drain 18.76
Footing drain (no. lhlcar ft: Page 2
Suite /bldgJapt. no.: I Project, naule: L-L(07T As i 402 Manufactured home utilities 50.03
Cross street/directions to job site :. Manholes 18.76
• • '7tam drain connector 18.76
. Sanitary sewer (no. linear R: ) 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.: Backflow preventes 31.27
. DESCRIPTION Of WORK ...... • • Backwater valve 12 51
Clothes washer • 25.02
k ) 0• S1.4 cl to ITR.. eatA / 4 1 e f � `(� �''1 " 1 Dishwasher 25.02 .
/
Drinking fountain . 25.02
Ejectors/srunp 25.02
❑ PROPERTY t O � WNER I U. TENANT Expansion tank 12.51 .
Name: RA GVk �J9ZIL 1.t ciCt `rtoff Fixauv/scwcr cap 25.02
Address: �( j '_ 10 . s ti) t2 t ST V Floor ge disposal sirlc/hub 25.02
Garbage disposal 25.02
City /State/ZIP: 1' i q co oc.. of 722 -* Hose bib 25.02
Phone: ( ) I Fax: ( ) Ice maker 12.51
❑ ' APPLICANT • ❑ CONTACE •PERSON Interceptor /grease trap 25.02
Medical Business name: .t) w 006 Co V( st m- c4 o VI I cc . Ras (value: $ ) Page 2
Primer 12.51
Contact name: , -'t l v, V/ N Iq .
Roof drain (co .1.. • rcial) 12.51
Address: 11145 5. 512x2 A J2
$ink/ba5i 11:25y 'Z,- 25.02 5o.e74{
: City /Stale/ZIP: To 1 a L., d 012_ Solar writs (potable water) 62.54
Phone: ( 504 4 v ! - i q q ck I Fax :: (5 ) 23) - 08 5 Tub /shower /shower pm 1 12.51 12 .5
E -mail: 4 ., L (1 ► Urinal 25.02
Water closet 1 25.02 °..OZ
CONTRACTOR
- / f Water beater 37.52
Business name: ' H pL V }1 F 1 L L_ L C Water pipina/17WV 56.29
Addres t- 5 +b (, Other: 25.02
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City /State/Z: \) a <O. v 23't. w A R S Cv G J
lP Vl U
Subtotal d "4.574.
Phone: (q 11) 5Q0 -- 7 I b Lt. Fax: ( ) ',graft mit fee: $72.50
CCB Lie.: 1 561 Zc 5 041 JI f Plumbing Lic. no.: ' '� ` Sit 8 P)g j G Pl review (25% of pclmit fcc)
Authorized aturz:
11t ITS State surcharge 02% of permit fee) •
TOTAL PERMIT FEE Gj $ ,Qa
Print name: - , 1 r/l(/ .t Date: d /./ , it...... This w pe apptitltion empires if a permit a not obtained within 180 days
! after it Ims beam =anted as complete.
"Fee methodology set by Tri- Cluny Building Industry Service Board.
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