Permit •
CITY OF TIGARD PLUMBING PERMIT
3 11 1 a ' COMMUNITY DEVELOPMENT Permit #: PLM2009 -00252
T f G AR D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/16/2009
Parcel: 1 S136AD01800
Jurisdiction: Tigard
Site address: 6805 SW PINE ST
Subdivision: Lot: 0
Project: Cardenas
Project Description: Installation of backflow preventer and (1) sink for home business.
Owner: FEES
CARDENAS, MICHAEL H /SANDRA J Quantity Description Date Amount
6805 SW PINE ST
TIGARD, OR 97223 1 ea Backflow Prevention - RES 09/16/2009 $27.55
1 ea Sink 09/16/2009 $16.60
PHONE: 1 12% State Surcharge - 09/16/2009 $8.70
Plumbing
Contractor: 28 ea Minimum Fee Adjustment - 09/16/2009 $28.35
Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
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 -0100. You may obtain a copy of the rules
or direct • _ - • • • ' NC by calling 503.246.6699 or 1.800.332.2344.
Iss ed By: / / / Permittee Signature: ,/
• Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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, \ Pa �l - UDG �
R �
'Building Fixtures C E \ ' J EO I oR oFlcf: USE USE ONLY LY
III City of Tigard
Date/By: c �Q i 1 2009 Received 9 /_ O Q ¥ Permit No.: / 4/6/44,0 6) a6
• 13125 SW Hall Blvd., Tigard, OR 97228 Plan Re : T rP 7
C Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Other Permit No.:
T I G A R D Inspection Line: 503.639 CITY OF T I O N Date Ready/By: Juris: RI See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVI Notified/Method: T� Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
® Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
® I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: 6805 SW Pine Street Catch basin or area drain 16.60
City/State /ZIP: Tigard, OR 97223 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Villa Ridge I Lot no.: Water service (no. linear ft.: ) Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer i Page 2
Adding sink Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
® PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: Mike & Sandy Cardenas Expansion tank 16.60
Address: 6805 SW Pine St Fixture /sewer cap 16.60
City/State /ZIP: Tigard OR 97223 Floor drain/floor sink/hub 16.60
Phone: (503)679 -5777 Fax: ( ) Garbage disposal 16.60
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax: : ( ) Sin asin/Iavatory / 16.60
ub /shower /shower pan 16.60
E -mail: Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: DLIL)IV �2 Water heater 16.60
Address: Other:
City/State /ZIP: Subtotal
Minimum permit fee: $72.50 7a. 5D
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) t
State surcharge (12% of permit fee) g 74'
Authorized signature: K • , O TOTAL PERMIT FEE 87• go
Print name: San-% �.e....4e1(1/4,s Date: 9 , 1 6/09 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.
I:\ Building \Permits\PLMF- PermitApp.doc 12/27/06 440- 4616T(10 /02/COM/WEB)