Permit CITY OF TIGARD PLUMBING PERMIT
a COMMUNITY DEVELOPMENT Permit #: PLM2012 -00193
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/16/2012
Parcel: 2S103ACO5500
Jurisdiction: Tigard
Site address: 12687 SW 113TH PL
Project: Burk Subdivision: HUMBOLDT CREEK ESTATES Lot: 6
Project Description: Installation of residential backflow preventer for irrigation.
Contractor: ALL NATURAL LANDSCAPE INC Owner: BURK, RICK R
PO BOX 2815 12687 SW 113TH PL
CLACKAMAS, OR 97015 TIGARD, OR 97223
PHONE: 503 -819 -9594
HONE: 503 - 740 -7733
FAX: 503 - 536 -6535
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 07/16/2012 $31.27
Specifics: 1 12% State Surcharge - 07/16/2012 $8.70
Plumbing
Type of Use SF 41 ea Minimum Fee Adjustment - 07/16/2012 $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 Not • 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 dire questions to NC by calling 503.232.1987 or 1.800.332.2344.
Issue By: 6 ' �� /� a...4/144 4 u
l�/ Permittee Signet re: Ce.r p 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.
Plumbing Permit Application
Building Fixture rttiz ()HALE l sr. ()\ IA
City y: �l a� /� Oh Pemvtxo.: Received t3' of TI and g ILI A042 -,0 ! p 3
I llIl • 13125 SW Hall Blvd., Tigard, O Plan Review
I Phone: 503.718.2439 Fax: 503.598.1M 1 6 MI Date/By: Other Permit No.:
Inspection Line: 503.639.4175 Date Ready/By: kris: ®See Page 2 for
T I G n It D Internet: www.tigard -or.gov of TIG LRD Notified/Method: Supplemental Information
TYPE OF W s DING + IS FEE* SCHEDULE
❑ New construction i I ' II olidon
�' For edal in orneation use checklist
Description Qty. Ea. Total
ja'Additiothlteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
I- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi-family SFR (3) bath 500.32
y 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: \ Q D 1 L , I'] ...p1a L..e Catch basin or area drain 18.76
City/State/ZIP: ., Q a r d 0 �, C -) a well, leach line, or trench drain 18.76
J _1 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
l..‘_.' F o n n € r Si-. 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.: Backflow preventer ' 31.27 3 (. 17
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
--L'CCQ Q4 \o? n Dishwasher 25.02
J Drinking fountain 25.02
Ejectors/sump 25.02
lgt PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name: \ ►� K / 1 r Floor drain/floor sink/hub 25.02
Address: '� (� $ 5 w 1 ` ?� �� ` Q C e Garbage disposal 25.02
City/State/ZIP: \ Q r d 0 12 q') a (3 Hose bib 25.02
Phone: ( 561 1 - q 5 q 1..,1 Fax: ( ) Ice maker 12.51
APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: A LL - t a_ 1 La v cisc,,Q ,e Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: n P_ c_L L U.S 5 1 ee
Roof drain (commercial) 12.51
Address: r) 'n A g $ 1 S Sink/basin/lavatory 25.02
City/ State/ZIP: /t ,-, L o K yy , a 5 () e 9 , 0 I S Solar units (potable water) 62.54
Phone: (563) ) ({ Q - ) 3 -3 I Fax:: 66 3) Tub /shower /shower pan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: 5Q nix .e 0.S aoO V L Water piping/DWV 56.29
Address: Other: 25.02
City/ State/ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50 74
CCB Lic.: (t4 '2 grit r / , 9- Plumbing Lic. no.: Plan review (25 % of permit fee) --
State surcharge (12% of permit fee) ' -1v
Authorized signature: � ` C
TOTAL PERMIT FEE
Print name: () ,e c t Lu s s \ e - I Date :1 -1 , - Ca This permit application after it has been accepted as complete.
within 180 days
a p
*Fee methodology set by Tri- County Building Industry Service Board.
I1Building \ Permits \P1.MU- PennitApp.doc 10 /01/09 440- 4616T(10/0 /COM/WEB)