Permit •
y
CITY OF TIGARD PLUMBING PERMIT
Permit #: PLM2012 -00352
COMMUNITY DEVELOPMENT
T IGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/04/2012
Parcel: 2S 110AC01101
Jurisdiction: Tigard
Site address: 11290 SW BULL MOUNTAIN RD
Project: Shell Gas Station Subdivision: 2003 -083 PARTITION PLAT Lot: 2
Project Description: Installation of ball valve, hose adapter and vacuum breaker of WCP Solutions (metered soap dispenser) in the
store.
Contractor: ROTO ROOTER SERVICE & PLUMBING CO Owner: PACWEST ENERGY LLC
28655 SW BOONES FERRY RD BY PAC WEST
WILSONVILLE, OR 97070 3450 COMMERCIAL CT
MERIDIAN, ID 83642
PHONE: 503 - 682 -9774 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 12/04/2012 $31.27
Specifics: 25 MiscOther Fee 12/04/2012 $25.02
1 12% State Surcharge - 12/04/2012 $8.70
Type of Use: COM Plumbing
Class of Work: ALT 16 ea Minimum Fee Adjustment - 12/04/2012 $16.21
Type of Const: Plumbing
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 Noti - - • er. 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 • uestions to OU b =- (ling 503.232.1987 or 1.800.332.2344.
Issu • d By: ` , . Permittee Sign. -
•
Call 503.639.4175 by 7:00 a.m. for the next available inspe • n 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.
From:Roto- Rooter 15036859754 11/30/2012 13:23 #920 P.001/002
Plallnbi Per mit A licatio , ED
Site Utilities
City of Tigard D C 0 3 2012 n a /1 /3 /.z PermitNo.: c f,/,0 z-CIO 315
: • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503 . 5 9�}F /� Date/By: Other Permit No.:
T ! c n I: u Inspection Line: 503.639.4175 1.11 i Wl' I�D Date Ready/By: rods: ® See Page 2 for
Internet: www.tigard -orgov BUILDING DIVISION : N° Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For spedal Information use checklist
Description I Qty. I Ea. I Total
ra Addition/alteration/replacement ❑ Other: New 1- 2-family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION ' SFR (1) bath 312.70
❑ 1- and 2- family dwelling T Commercial/industrial sFR ( 437.78
❑ Accessory building ❑ Multi - family SFR (3) bath 50032
❑ Master builder Each additional bath/kitchen 25.02
❑ Other: Fire sprinkler (_- sq.11.) Page 2
JOB SITE INFORMATION AND Site utilities:
t D LOCATION n `
lob site address: 1 1 0 6C A2) C7( ).' l (Y�fl,� n _i.t'1 „G Catch basin or area drain 18.76
City/State/ZIP: �� � r(> t'1 Drywell, leach line, or trench drain 18.76
I �"t`, /1 1 Footing drain _J (no. linear ft.: Page 2
SuiteibldgJapt. no.: Project name: ViDc4Ci e �.(i. 1,75 ,1-4770 IV Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear R:.__, Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear R: ) Page 2
Subdivision: I Lot no.: Fixture or Item: ,
Tax map /parcel no.: Bacldlaw preventer 31.27 3/..2- ?
DESCRIPTION OF WORK Backwater valve 12.51
\ �, � t- Clothes washer 25.02
`� T k1Ore- \\ ^ )CA \\ U ( kC 1Q_ C `.7 r\c% I \ C6 `` Dishwasher 25.02
C' ( yr �(X : 3.. , ci. Drinking fountain 25.02
04 ,67 t) to Ptc u Lk-1-f Z Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cep 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib
25.02
cs Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name: Medical gas (value: $ � ) Page 2
Primer 12.51
\ Contact name: Roof drain (commercial) 12.51
N Address: Sink/basin/lavatory 25.02
Op City/ State /ZIP: Solar units (potable water) 62.54
i Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
M E -mail: Urinal 25.02
0 CONTRACTOR �r Water closet 25.02
Water heater 37.52
1 Business name: sk ibmoh �,i.: CCf4(),C w fiwy ,(4 r • watePipingfpWV 56.29
ti Address: or ► t a.' _ '! &lr]a _ ' ,i Other Bat_ ✓iti w I 25.02 a.. oa
(T City/state/ZIP: all � �, „b+� •�� 140A t ADrt/''it2 Subtotal
Phone: (�' • „ • 11]x■ �t11•il'' 1 Minimum permit fee: $72.50 ' ,
CCB Lic.: ' T1 1 0 1 1 t 4 Plumbing Lic. no.: 37- 7 4, ' Plan review (25% of permit fee)
Authorized signature: 7/f /0( State surcharge (12% of permit fee)
�
�,
_ TOTAL PERMIT FEE I
print nanle. 0. A ` `• r- - J i 1 Date: 1 t 80 ia This permit application expires If a permit is not obtained within 1811 days
after it has been accepted as complete.
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