Permit CITY OF TIGARD PLUMBING PERMIT
• COMMUNITY DEVELOPMENT Permit #: PLM2013 -00177
TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503.718.2439 Date Issued: 06/06/2013
Parcel: 2S103BB01900
Jurisdiction: Tigard
Site address: 12355 SW 124TH AVE
Project: ANDRE Subdivision: BROOKWAY Lot: 19
Project Description: Replacing 40 ft. of water service.
Contractor: PIPELINE PLUMBING Owner: ANDRE, RONALD & MURIEL
333 S STATE ST SUITE V -108 12355 SW 124TH AVE
LAKE OSWEGO, OR 97034 TIGARD, OR 97223
PHONE: 503 - 590 -2424
HONE: 503 - 624 -1906
FAX: 503 - 624 -1926
FEES
Quantity Description Date Amount
40 If Water Service 06/06/2013 $62.54
Specifics: 1 12% State Surcharge - 06/06/2013 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment - 06/06/2013 $9.96
Plumbing
Class of Work: ALT
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 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:
/
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.
Jun 05 13 02:26p Adam Faren 5036241890 p.2
RECENED
Plumbing Permit Application
Site Utilities JUN 0 5 2013
City of Tigard CITYOFTIGARD R 6 �S ( 3 43-7) Perm° Ho: Pit"e0 /3 - oai /77
14 . + 13125 SW Hall Blvd., Tigard, 0 Plan Review
Phone: 503.718 2439 Fax: D atrlB y . Other Permit No.:
Inspection Line: 503.639.4175 Date Ready/By: :Ws El See Page 2 for
Ti t; 1 R.D Internet www.tigard -or.gov Notified/Mdhod: l t 6, Sopplemental information
TYPE OF WORK
I FEE* SCHEDULE
❑ New canstrtrdioa ❑ Demolition
For special information use checklist
Description i Qty. I Ea. I Total
® Addition/alteratiaoheplacemcit ❑ 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 ❑ Commercial/industrial SFR (2) bath 437.78
SFR (3) b 50032
❑ Accessory building 0 Multi-family Each additional bath/kitchcn 25.02
❑ Master builder ❑ Other. Fire sprinkler (_ sq. R) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
- Catch basin or area drain 18.76
Job site address: 12355 SW 124th Ave
Drywell, leach line, CO trench drain 18.76
City/State/ZIP: Tigard Oregon 97224 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
Rain drain connector 18.76
Sanitary sewer (no. linear R: _) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft: 40) I Page 2 62.54
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
Backwater vahe 12.51
DESCRIPTION OF WORK
Clothes washer 25.02
Replacing water service Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name: Ron Andre
Floor drain/floor sink/hab 25.02
Address: 12355 SW 124th Ave Garbage disposal 25.02
City/State/ZIP. Tigard Oregon 97224 Hose bib 25.02
Phone: (503)590 -2424 Fax ( ) Ice maker 12.51
® APPLICANT ® CONTACT PERSON interceptor/grease trap 25.02
Business name: Pipeline Plumbing Medical gas (value: S ) Page 2
Primer 12.51
Contact name Terra Vickermau Roof drain (commercial) 12.51
Address: 333 S State St #V-108 Sink/basin/lavatory 25.02
City /State/ZIP: Lake Oswego Oregon 97034 i Solar units (potable water) 62.54
Phone: (503) 6241906 I Fax:: (503) 624-1926 Tub /shower /shower pan 12.51
Urinal 2.5.02
E -mail: pipelinereception@frontier.com
Water closet 25.02
CONTRACTOR Warr heater 37.52
Business name: Pipeline Plumbing - . Water piping/DWV 56 29
Address: 333 S State St #V -103 Other: 25.02
City/State/ZIP: Lake Oswego Oregon 97034 Subtotal 62.54
Phone: (503) 624 -1906 Fax: (503) 6241926 ,_ Minimum permit fee. 872 50 72.50
Plan review (25% of permit fec)
CCB Lie.: 158260 t/ / Plumbing Lic. no.: ? 5-10
3 State surcharge (12% of permit fee) r. 70
Authorized signature: T\/ \ / O r - - -- ANVIINA j TOTAL PERMIT FEE 3-1. 2-6
Date: 06-05 This permit application expires if a permit is not obtained within 180 days
Print name: Terra Viekertnan after it has been accepted as complete
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