Permit CITY OF TIGARD PLUMBING PERMIT
Z; • COMMUNITY DEVELOPMENT Permit #: PLM2012 -00178
T I G pR D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/25/2012
Parcel: 1 S133DD08300
Jurisdiction: Tigard
Site address: 11624 SW 128TH AVE
Project: Locsin Subdivision:'ILLAGE AT SUMMER LAKE PARK NO. Lot: 120
Project Description: Kitchen remodel, relocate (1) sink, (1) laundry tray and (1) water heater.
Contractor: D & B PLUMBING, INC Owner: LOCSIN, ARSENIO Z
PO BOX 686 11624 SW 128TH AVE
OREGON CITY, OR 97045 TIGARD, OR 97223
PHONE: 503 - 657 -7423 PHONE:
FAX: 503 - 657 -7396
FEES
Quantity Description Date Amount
1 ea Sink 06/25/2012 $25.02
Specifics: 1 ea Laundry Tray 06/25/2012 $25.02
1 ea Water Heater 06/25/2012 $37.52
Type of Use: SF 1 12% State Surcharge - 06/25/2012 $10.51
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $98.07
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or direct quest • to O to C by calling 503.232.1987 or 1.800.332.2344.
Issued B t / Permittee Signature: A,
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
. F111t OFfl( l til•: ()NIX
City of Tigard AE82.2319CEIVED R �ed 1 p?016-• /0A ! . Penait No.: , ( , /A -(x) /z$ . • 13125 SW Hall Blvd., Tigard Plan Review
Phone: 503.718.2439 Fax 50 3.59 V 6Q Date/By: R Other Permit No.:
I. 1 _ \ i ) Inspection Line: 503.639.4175 N 2012 Date Ready/By: . Suns: ® See Page 2 for
Internet: www.tigard or.gov Notified/Method: _ Supplemental Information
TYPE OF V °RIO•' ° FEE* SCHEDULE . (10 . t &m r 1 • For special information use checklist
El New construction 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 (t) bath 312.70
437.78 t
❑ 1 = and 2- family dwelling ❑ Commercial/industrial (2) bath industrial SFR (3) bath 500.32 •
❑ Accessory building ❑ Multi- family Each additional bath/kitchen 25.02 IJ
❑ Master builder ❑ Other:. Fire sprinkler ( sq. ft.) - - Page 2
JOB SITE INFORMATION AND LOCATION Site utilities: - - V
Catch basin or area drain 18.76
Job site address: //‘ 570 /21 ��, Diyw pp
ell, basin or line, or trench drain 18.76 T
City / State/ZIP: jap -�P ofe Footing drain(no.linear ft.: ) Page 2 M
Suite/bldgJapt. no.: U I Project name: L(}L5/ /3 Manufactured home utilities 50.03 (�
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76 1 Sanitary sewer (no. linear .ft.: ) Page 2
Storm sewer (no. linear ft.: _) Page 2 -N
Water service (no. linear ft.: ) Page 2 V
Subdivision: I Lot no.: Fisture or item:
Tax map /parcel no.: Baekflow preventer 31.27 0
Backwater valve 12.51 W ^
DESCRIPTION OF WORK 25.02 O
Clothes washer
l l Te..i + E (3 - / - eO D g 4-•-• Dishwasher 25.02
• Drinking fountain 25.02
Ejectors/sump 25.02
.PROPERTY OWN R l ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name: pG 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 ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Business name:
Primer 12.51
Contact name: Roof drain (commercial) ' 12.51
'Address: Sink ly d/basin/lavatoam; 25.02 ty'a. ,
City/State/ZIP: Solar units (potable water) 62.54
Phone: ( )' Fax: : ( ) Tub /shower /shower pan 12.51
Urinal 25.02
E -mail:
Water closet 25.02 s �
CONTRACTOR Water heater / 37.52 $ 77 -
Business name: . / `.J /fi .n h? ' /N S Zj c , Water piping/DWV 56.29
( �
Address: �n° :7 ,f 7 �Y / 4"/ � Other: 25.02
r �
v n 1 '/ Subtotal :J
City / State/ZIP: L , 7 1 / Oi' 9 S ?
^ i - Minimum permit fee: $72.50 --------N Phone: ( Sod),, ?' j - t� Fax: (SW )vlS7 759‘
Plan review (25% of permit fee) ..--
CCB Lic.: 4////0 & ( t (' Plumbing Lic. no.: ey7/04;" State surcharge (12 %of permit fee) /0. dcl
Authorized signature: ?: •,/ 19 , TOTAL PERMIT FEE i , � 7
� j This permit application expires if a permit is not obtained withi SO days
• Print name: ,z c, . ` 5e Date: k fib` / z after it has been accepted as complete.
/ I ` *Fee methodology set by Tri- County Building Industry Service Board.
t: IBuildingTermiu \PLMU- PermitApp.doc 10/D1/09 440.4616T(10/02/COM/WEB)
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