Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2012 -00145
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/30/2012
Parcel: 2S110CB08500
Jurisdiction: Tigard
Site address: 12499 SW ST ANDREWS LN
Project: Mountain View Estates, Lot 10 Subdivision: MOUNTAIN VIEW ESTATES Lot: 10
Project Description: Residential backflow preventer for irrigation
Contractor: MALMEDAL ENTERPRISES INC Owner: JT ROTH CONSTRUCTION INC
PO BOX 207 12600 SW 72ND AVE
BANKS, OR 97106 TIGARD, OR 97223
PHONE: 503-324-0759 PHONE: 503 - 639 -2639
FAX: 503 - 324 -0580
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 05/30/2012 $31.27
Specifics: 1 12% State Surcharge - 05/30/2012 $8.70
Plumbing
Type of Use SF 41 ea Minimum Fee Adjustment - 05/30/2012 $41.23
Plumbing
Class of Work: OTR
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 questi. • to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued = : / � 4 / Permittee Signature:
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. •
Plumbing Permit Application
Building Fixtures FOR OFFICE USE ONLY
Received
Ci of Ti and DateB : , ' Perm No.: ( �4a
V 13125 SW Hall Blvd., Tigard, OR 97223 y 5 i+a - Od
IN Plan Review
I Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.: {*9 ra0//.(,01y7
Inspection Line: 503.639.4175 Date Ready/By: Juris: H See Page 2 for
TIGARD Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK - FEE* SCHEDULE • - • ;
New construction ❑ Demolition For special information use checklist.
Description I Qty. I Ea. f Total
❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
14 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
building SFR (3) bath 500.32
❑ Accessory g ❑ 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: p.14•11 Sal S- - L
. Catch basin or area drain 18.76
City /State /ZIP: v) c A o� 61-3--a . �77 Footing drain line, lior near trench drain ag 2
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Project name: ( � •
'�'D�?• � \ Q.e..l Manufactured home utilities 50.03
Cross street/directions to job site: A ,,,,, ` t [...ei Sk Manholes 18.76
6V fk L'. 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 4 4v„%_ V i __ An / Lot no.: tb Fixture or item:
Tax map /parcel no.: Backflow preventer ) 31.27
DESCRIPTION OF WORK . , Backwater valve 12.51
14.- a-12..rS -4 `1 - / 6�4J -4 Clothes he rher 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ 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 . . . - ` • - PERSON, ❑ CONTACT PERSO . • , Interceptor /grease trap 25.02
Business name: t \ � Dye Medical gas (value: $ ) Page 2
Contact name: v �� , Q Primer 12.51
11 "'' '� Roof drain (commercial) 12.51
Address: S 4J Thad P ` j ( S' J pt kf' Sink/basin/lavatory 25.02
City/State/ZIP(( / c/fg. cf •.aa'5 Solar units (potable water) 62.54
Phone: 0:65 ) - yglo Fax: : (C33) f -d �'3 9 Tub /shower /shower pan 1 2.51
E -mail: s4- r e 1 .�, . , fit,,,, Urinal 25.02
J CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: ( Envyr Water tin
P g/DWV 56.29
Address: P L Q70X g - 0 f Other: 25.02
City /State/ZIP:
QLv.tk( s f7 93406 Subtotal
Phone: ( ) ;a4f- 0 7,51 Fax: (5)73 ) 3,D4 c ' Minimum permit fee: $72.50 7 a .50
( a, Plumbing Lic. no.: Plan review (25% of permit fee)
CCB Lic.: Gp
Ade/ State surcharge (12% of permit fee) ' 70
Authorized signature: c/30//c1
TOTAL PERMIT FEE g /. go
kil Date: This permit application expires if a permit is not obtained within 180 days
Print name:
I 1 " ' 2 � t after it has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
I:\ Building \PermitslPLMU- PermitApp.doc 10/01/09 . 440- 4616T(l0 /02/COM/WEB)