Permit �
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C ITY OF TIGARD PLUMBING PERMIT
P ERMIT #: PLM2006 -00396
� DEVELOPMENT H BMEN9 OR 2CES -639 -4171 DATE ISSUED: $/2$/2006
PARCEL: 1S133DA-04600
SITE ADDRESS: 12590 SW GLACIER LILY CIR ZONING: R -7
SUBDIVISION: AMART SUMMERLAKE LOT: 068 JURISDICTION: TIG
Project Description: 75 ' water service replacement.
CLASS OF WORK: OTR GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: 75 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
HOUSTON HICKENBOTTOM
12590 SW GLACIER LILY CRL Description Date Amount
TIGARD, OR 97223 [PLUMB] Permit Fee 8/28/2006 $72.50
[TAX] 8% State Surcha 8/28/2006 $5.80
Phone : 503 -524 -6128 Total $78.30
Contractor:
WOLCOTT PLUMBING CONTRACTORS
1075 W COLUMBIA RIVER HWY
TROUTDALE, OR 97060 REQUIRED ITEMS AND REPORTS
Contact # : PRI 503- 235 -8784
FAX 503- 491 -2932
Reg #: LIC 23847
PLM 26 -208PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued By: Permittee Signature:
_ge
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.
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. . : -!
t ins Permit A i t1 E VE® FOR OFFICE USE ONLY
of SW l�atl'B Tigard, OR 97223 A U G 2 5 ZOO 6 Datdey �� � 0� i �' • " � , ,
: 503.639.4111 Fax: 503598.1960 Plan Rew
r` ., : r ? Other Permit No.:
-'our Inspection Line: 503.639.4i75CITY OF TIGARD a.1 ,11,.:-.111
'. C www.ci.tigard_or.us BUILDING DIVISI •o , Date Ready/By. 1 in See Page 2 for -
Nofilled/Method: Suppletnentat taforrnarlon
TYPE OF WORK FEE* 3GWiDUL)?
a IIew construction ❑ Demolition - For special information use checklist
Description Qty. t a. Total
Addition /altenttionhcpIaccment [] Other: _
New 1.- 2-fam7y dwellings (includes 100 R. for each utility connection)
' CATEGORY OF CONSTRUCTION SFR(1)bath I 249.20
1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
0 Accessory building 0 Multi - family SFR (3) bath 399.00
-
Each additional bath/kitchen 45,00
0 Master builder 0 Other:
Pirc sprinkler ( , sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address ( 0 fal G...ka,Lz.B a inel,„L. R Catch basin or area drain 16.60
City/State/ZIP: 7:14:111.k_152, 01'2.13 - Drywcll, latch line, or trench drain 16.60
Suite/bldg./apt. no.: Project name: til Kt�wl `/ t B v4 Footing drain (no, linear R: ) Page 2
Cross streci/directions to job site: t Minn Poctured home utilities 110.00
Manholes 16.60
' ' poN v 3 Rain drain connector 16.60
Sanitary sewer (no. linear ft: ) Page 2
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Storm sewer (no. linear R: ,__) Page 2
Subdivision: Lot no.: Water service (r,o, linear ft.: ) Page 2 ST. OG
Tax map/parccl no.: -
Fixture or item
Absorption valve 16.60
1)ESC:REPTION OF WORK Fisckflow prcventer Pagc 2
NV �i IL � �.,V 7 (Xi 0, our Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
XPROPERTY OWNER I 0 TENANT - Drinking fountain 16.60
Ejectors/sump 16.60
Name: ow( 00 w( i l porn Expansion tank 16.60
Address: Z b , G- ce. - Fixture/scwcrcap 16.60
City/State Z.IP: '4 l.J z o n q j 3 Floor drain /floor sink/hub 16.60
Phan 3) 1+ � (,lr Giz A Fax: ( ) Garbage disposal 16.60
PLIC'ANT 0 CONTACT PERSON Hose bib 16.60
Ice maker 16.60
Business name: Wolcott Plumbing dba Jack Flowk Plumbing y Interceptor/grease trap 16.60
Contact name: Zs Medical gas (value: S ) Page 2
Address: 1075 W istoric Columbia River Hwy Primer 16.60
City /Stale/ZIP; Trnutdale, OR 97060 Roof drain (commercial) 16.60
Phone: (503) 235 -8784 t Fax: : (503) 491 -2932 Sink/basin/lavatory 16.60
Tub/shower /shower on 16.60
E -mail: -
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: Wolcott Plumbing dba Jack Hawk Plumbing Water hatter 16.60
Address: 1075 W Fllstoric Columbia River Hwy Other: •
City /State/ZIP; Troutdale, OR 97060 Subtotal
• Minimum permit fee: 572.50
Phone: (503) 235-8784 Fax: (503) 491 -2932 Residential backflow minimum permit fee: $36.25.50
,.. CCB Lic.: 23847 Plumbing Lie. no.: 26 -208 PR - Plan review (25%ofpermit fee)
State surcharge (8% of permit fee) 8 0
Authorized signal ' • TOTAL PERMIT PEE r 13
L - erairia F ' '' - . - ." Date: , Z$ / w This permit application expires If a permit is not obtained within
-/ 180 days after it has been accepted as complete.
*Fee methodolocv set by Tri- County Buildine Industry Service Board.
U8/28/2006 1E:53 FAX 5AARA8t01:10 CITY OF TICARD g1002
. ..' ".. 1
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1 1 11 1
Building Division
cARD Request for Permit Action or Refund
Ti
TO: CITY OF TIGARD
Peimit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223 40 I
Phone 5033112430 Fa)c 503.59&1960 www.tigard-oriscry 6.,,C //),.. 2 0
'No,
FROM D Owner 0 Applicant )<COAtractor El CitY Of° t °
(elmck one) /1 V 9 0
/ 0
REFUND TO: NOM:
(73naltmaa or Iodividval) (5 C 1( AtCrU3 k. LO M) NA is-- 41 .
Mailiog Address: 01,0 l'illaW__Cilli en ef___
V 0 1 0 city/state/zip: 1 A in.stwgI_________
7» -7-E4WN/E- Phone No.: - 13 - 1,__E______—
org/04 A/
PLEASE TAKE ACTION FOR THE rIM(S) CHEC133D (1)
:I CANCEL PERMIT APPLICATION.
.7. . REFUND PERMIT FEES (attach receipt, if available).
• REMOVE CONTRACrOR FROM PERMIT (do not cancel penult).
P=it #: P 1-11 wocr- 0316 ___
Site Address or Paxcel #: ' 64. 143=/ilX_______
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Project Name: HILICerti BO TTO M
Subdsion Na irtC: Pill Fra-V 4arklmin- OrK1 Lot #: (Dc3?)_
EXPLANATION: OJMes tK-€ r COAAkepakt4 . ( hcuJt v.,* cecttutl
a I rim& . ci , e i?. ik)tit , ‘ 1 •
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Signature: Af',11 Datc
Print Namc: 412#4 /1.16/0e(,5
Rciaid2elis1
1. The Elnildiatt Offielal may authorize the reftmd of
a) any Cm which was ceroceously paid oe =Hama.
h) net mete than 80 percent of the permit fee for issued nemtltantiot to PIT in3 &
c) ram more than 80 postmen of plan mynas fee when an application is canceled before any plan teview efTen hub= ettpeneled.
/ Rands sell be returned to the original Payer in the 9202C method in which payment tom feeMivatl .
' I cFICL 1 '::L, LINI...1
Rt to 5 Mimi= Date ! ale UMW Rae to B ,., Admix': Date B •
Wind Procuscd Dalc " -10104 MirA Invoice reaceStett Date IiiIIIIIIII
Pendt Canceled: Date ' fe , ,. 167„ Parcel Ta Added: Date
Receipt # A0, Date jig : OG , e . • • . - Amount $ ik, s
zusuutuvwertnARcve.±Acd. ..-. -- Rev 03 / 211 / 0 ....e:ia l _
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