Permit CITY OF TIGARD PLUMBING PERMIT
` COMMUNITY DEVELOPMENT Permit #: PLM2012 00312
?1GARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439
Date Issued: 10/25/2012
Parcel: 2S104ACO2000
Jurisdiction: Tigard
Site address: 13075 SW HAMPTON CT
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Project: Subdivision: 1990 -043 PARTITION PLAT Lot: 2
Project Description: Replace 20 ft of water service.
Contractor: RAYBORN'S PLUMBING INC Owner: JORDAN, MARC A & HANNAH S
19990 SW CIPOLE RD 13075 SW HAMPTON CT
TUALATIN, OR 97062 TIGARD, OR 97223
PHONE: 503 - 692 -4139 PHONE:
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
20 If Water Service 10/25/2012 $62.54
Specifics: 1 12% State Surcharge - 10/25/2012 $8.70
Plumbing
10 ea Minimum Fee Adjustment - 10/25/2012 $9.96
Type of Use: SF Plumbing •
Class of Work: OTR
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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Required Items and Reports (Conditions)
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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: Q,�
N /
/� 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.
-503 691 2328 Rayborns Plumbing 03:24:07 p.m. 10 -25 -2012 2 /2
Plumbing Permit Application
Building Fixtures E t
City of Tigard RE R eceived
Date/By: / 3 % -Permi N 0�� � / a / � /
II
• 13125 SW Hall Blvd., Tigard, OR 711703r C
B Phone: 503.639.4171 Fax: 503.5984'0 m 5 2-4I Plan Review Other Permit No.:
Date/By:
1 1 t n 1t U Inspection Line: 503.639.4175 {�/ Date Ready /By: lmis Sec Page 2 for
Internet: www.tigard- or.gov C I I OF T�U( Notified/Method: supplemental Informat
TYPE 0 • y . .11 DI‘ FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist.
Description I Qt I Ea. I Total
2 / Addition /alteration /replacement ❑ Other: New 1- 2- family dweUings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
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: 7 Catch basin or area drain 18.76
17 O _51.,..) C 1 Drywell, leach line, or trench drain 1 8.76
City /State /ZIP' q•-•,.;4.7
t a.m �' Q 3 Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: _) ' "Page 2
Water service (no. linear ftC22 � ✓ ✓ // Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
r Clothes washer 25.02
`C iJ (4-4 e 1. ci 1s: ° . ' .- r a :I, c v Dishwasher 25.02
Drinking fountain 25.02
• Ejectors/sump 25.02
IRCPROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name:
,-r 2 D M A-12c lc � -ANNA- 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 ❑ CONTACT PERSON Interceptor /grease trap 25.02
i s ■ Medical gas (value: S _) Page 2
Business name: K
v� r ref Pt �ti 1 . it t 1 i .
Contact name: ; �•' Primer 12.51
�'` ✓✓✓��� r / p Roof drain (commercial) 12.51
Address: /Gy 6 ( b/e I� ([J� ,Ct. Sink/basin/lavatory 25.02
City/State/ZiP: � l �s- Q y Q 7O6 2. - Solar units (potable water) 62.54
Phone: (,;o3) 6 9., - q / 2 q I ( 3 ) Fax: : i,3) 6 y�. Tub/shower /shower pan 12.51
/ Urinal 25.02
E-mail: /-[ of 1 C @ 1/Cy rvt e� ,., �,-_, O 1
y Water closet 25.02
CONTRACTOR .
PI I- Water heater 37.52
Business name: tuOdN S T L . 644.41 P l A4 . ( ti L Waterpiping/DWV 56.29
Address: /4Q'gb a �/ /' V Rd Other 25.02
City/State /ZIP: ! ; !a t .. r' («E� Subtotal
/� /Phone: (. 3) i72.. /� 3y - Fax: (iO3) 69/ - 2 3 Minimum (25% permit fee: 572.50
.4./.
� CCB Lic.: !. ' / Plu . • • : ic. no. ' . Plan review (25% of permit fee)
r T
^,� _ State surcharge (12% of permit fee)
Authorized signature:
�,, ati1✓' • " /' , f TOTAL PERMIT FEE
Print name: , +' r t', ff Date: " }'` This permit application expires if • permit Is not obtained wit d ays
r-'';0 'o • r�
: , , i t i " �i' ' ' % + - -- after it has been accepted as complete.
"Fee methodology set by Tri County Building Industry Service Board.
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