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Permit (190) ilECEIVED V 0 I F.) MAY 2 0 2019 CITY OF 'TIGARD BUILDING DIVISION City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Na I, Request for Permit Action 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-oLgoy TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: 0 Owner Applicant Contractor p City Staff Check(1)one REFUND OR Name: INVOICE TO: (Bwinefts IndividLua) Dirtworks Excavation LLC Mailing Address: 2221 SE 53rd Avenue City/State/Zip: Hillsboro OR 97123 - Phone No.: 503-753-7562 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): OID PERMIT APPLICATION. (10/V7714-c_rar-7L, 14 67 Ceti/W:717A - D PERMIT FEES (attach copy of original receipt and provide explanation below). a OICE FOR FEES DUE(attach case fee schedule and provide explanation below). Permit#: PLM2019-00185 Site Address or Parcel#: 12180 SW Merestone Court,Parcel SEG664 Project Name: Biagden,Melissa M. Subdivision Name: Lot#: EXPLANATION: Contractor injured,unable to complete project-refund requested of contractor pmt$81.20 E.Z."7/ t1472-k- erltiAre—A" )6/4 ctionic. • • ,4"cif Signature: Date: 5/16/19 Print Name: Bobbie Joe Do on,Jr. Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of. • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. C-Z) /cy, 5 0 --- • ei, Plo V• 96 tit III I It I I 1)NI Route to Sys Adam: Dare By Route to Records: Dare , `401/12, 13. Refund Processed: Date e5y,:a., Invoice Processed: Date By Permit Canceled: Date ef/,p_A ? S Parcel Tag Added: Date By tABuiatalgWonus itevemaimeaan jAsiKaor a TIGARD City of Tigard August 9, 2019 Dirtworks Excavation 2221 SE 53`d Ave Hillsboro, OR 97123 Re: Permit No. PLM2019-00185 Dear Applicant: The City of Tigard has processed a refund for fees on the above referenced permit(s) as follows: Site Address: 12180 SW Merestone Ct Project Name: Blagden Job No.: N/A Refund: ® Check#232909 in the amount of$64.96. ❑ Credit card "return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit" receipt in the amount of$ Comments: Per applicant's request as a different contractor performed the work on this permit. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171. TTY Relay: 503.684.2772 • www.tigard-or.gov City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Dirtworks Excavation DATE: 8/2/2019 2221 SE 53`d Ave Hillsboro, OR 97123 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 423224 Case#: PLM2019-00185 Date: 5/2/2019 Address/Parcel: 12180 SW Merestone Ct Pay Method: CreditCard Project Name: Blagden EXPLANATION: Per applicant's request as new contractor performed the work. Per building official, refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $ Amount Plumbing Permit 230-0000-43101 $58.00 12%State Surchage 100-0000-24001 6.96 TOTAL REFUND: $64.96 APPROVALS: SIGNAT ES DA E: If under$5,000 Professional Staff t f. If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: d// 7/_ / By: ) y I:\Building\Refunds\RefundRequest.doc x 09/01/2010 111 CITY OF TIGARD RECEIPT • ' 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 -F r r, A r,.D Project Name: BLAGDEN , Site Address: 12180 SW MERESTONE CT Receipt Number: 436094 - 08/27/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00185 $-64.96 Total: $-64.96 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 232909 DHOWSE 08/27/2021 $-64.96 Payor: Dirtworks Excavation Total Payments: $-64.96 Balance Due: $64.96 Pant. 1 of 1 CITY OF TIGARD RECEIPT ; 11; 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: BLAGDEN Site Address: 12180 SW MERESTONE CT Receipt Number: 423224 - 05/02/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00185 Sanitary Sewer 230-0000-43101 $62.54 PLM2019-00185 12% State Surcharge-Plumbing 100-0000-24001 $8.70 PLM2019-00185 Minimum Fee Adjustment-Plumbing 230-0000-43101 $9.96 Total: $81.20 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 002406 PUBLICUSERO 05/02/2019 $81.20 Payor: Sheryl A Dorton Dirtworks Excavation Total Payments: $81.20 Balance Due: $0.00 Paae 1 of 1 DocuS'iann Envelope ID:D69404C2-4325-41 D4-912D-0E1834E958CD i 1 auua u, I VI HILL t1pEJ11‘ALWUll Site Utilities City of Tigard E I0/ R om �j Ph V Permit No.: Q f�`! ` % s,- • 13125 SW Hall Blvd.,Tigard,OR 97223 DaterBy: QW )( _ ' Phone: 503.718.2439 Fax: 503.598.1960 Plan Ravrew Other Permit No.: Date/By: T I G A R D Inspection Line: 503.639.4175 MAY 1 b 2019 Date Ready/By: Anis ® See Page 2 for Internet: www.tigard-or.gov Notified/Method: Su elementallnformahon ' i ,+Mir,'µ ',,1 „ 5. Et} :E i.€ 4 2 S.� fgeu ,,..A a „s ,yZ W -._ay., I K €..s (ems aaa a e z. g' 4 r, '¢E e r UE€a � I� ❑New construction ❑ r 111410 �I � II' 1 For special information use checklist T Description [ Qty. I Ea. 1 Total ,'Addition/al terationheplacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) e10 sa.t£�s. rr u 001,,$ SFR(1)bath 312,70 -and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78 ❑Accessory building 0 Multi-family SFR(3)bath 500.32 ❑Master builder 0 Other: Each additional bath/kitchen 25.02 xy"� I'iJS 9 ' heat r9"n i t -:m.�, -: cs - t it '.- Fires sprinkler sq.ft.) Page2 - ' ll`I �i R r - R411, E1N 9`ir�'�4 ;i, ' illl i 't 1 Site utilities- Job Job site address: 1 2 j c Q S y. r l- ' eS e c+_ Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP: 0 T c&r / 011-7,-2 Footing drain(no.linear ft.: ) Page 2 SuittA4dgraap1 nn_ Project name: Manufactured home utilities 50.03 Cross street/directions to job site: 5 I,2 l At-V.C 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 ft.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: 0 � la ( �� isk Backflow preventer 31.27 t og,1,4,, �i ; v, o.v : Backwater valve 12.511 Arti:} ey :a i t n k :t .,p . D ( .C*MI ` Clothes washer 25.02 PLM2019-00185 Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 ..: I"SS M' 1 i!tJi':F� �f 'Puy t H�'-'S � jQt � A � _ €•k k ,. _ � �p i ` # i r i �: :SiExpansion tank 12.51 �._ . s*4�;©rw: � �� �.l�. ��I�>�"r f°'.a't_. .6 :_az�, ,:�„ . � i*=a pans Name: e1jss4i 1516,9 eaen/4her✓In 7.Arebabc n�'� Fixture/sewer cap 25A2 Address: k 'L)4 V w �,e r S-tV•y� c-1- GFarbage grain/poor sink/hub 25.02 arrbb age disposal 25.02 City/State/ZIP: -Ft 3 A r-d Vim- Z eZ-4--2-2-3 L �,(me$�- Hose bib 25.02 Phone:(q11) (p LIS- $1 S€i t:(awl) .3t..f 011049() Ice maker 12.51 I. .J 'ps't lI P h r al -a- tt rf 5 a Interceptor/grease trap 25.02 - - Business name: Medical gas(value:$ ) Page 2 Primer 12.51 Contact name: NI,e l 1 S S el 51,01. Lr),C Y- /sl1e1r yl n Address: 1,, t"C bG�b�K�nd� Roof drain(commercial) 12.51 f 2-10 o CI / Vie r e S4oll2. C-f ` 1 Sink/basin/lavatory 25.02 City/State/ZIP: 1 i J ail rd j 0 Gi 2 2 j Solar units(potable water) 62.54 Phone:(L 7-?) 6 Li S Cj 2- ) t:(G[�j) •�L.-'1,-.f p`(Ole D Tub/shower/shower pan 12.51 E-mail: W/1 C d-e n 2---- - c� pt i at 1 C 0 A Urinal 25.02 2+"+ li hl. :'i"3'r. '�-k 5.:rj ''' �u 1, , 3,1 r r. Water closet 25.02 +;: to-,?:.�tl{�+ �'�.:.�It!Kt lw�ri,u.��i:t �3 ,N. �i iltil 1 f 1'll$ - ...`:, . .::. '. i,���;r"r,�!. .�iti+,I�� .�k Water heater 37.52 Business name: Clog Busters LLC Water piping/DWV 56.29 Address: 2900 SE Cornelius Pass Rd#549 Other: 25.02 City/State/ZIP: Hillsboro,OR 97123 Subtotal Phone:( 503)680-8947 Fax:( 503)530-8494 Minimum permit fee: $72.50 CCB Lic.:200212 oocusigned by: Plumb;rtg'JRe94fi6!�E383 Plan review (25%of permit fee) Authorized signatureSSA, Oit L.IA, Sew rianifellfdr.‘14 State surcharge(12%of permit fee) TOTAL PERMIT FEE 64510A1 C1 F46A... -Mc 4uT✓ s., This permit application expires if a permit is not obtained within 180 days Print name: Me 11 s s' Sherwin Date./��/2 019 after it has been accepted as complete. B l ag(len ruhahalran ai *Poo aunbodolony.M .Tai Comity Building Wormy Sorhe.Board ---- L1BuildingTemits\PLMU-Pem.itApp.doc 10101/09 440-4616T00/02/COM/WEB) CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit PLM2019 00185 t 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date issued: 05/02/2019 t, ,3),11 9 Parcel: 1 S134CC00900 Jurisdiction: Tigard Site address: 12180 SW MERESTONE CT Project BLAGDEN Subdivision: MERESTONE Lot 9 Project Description: Replacing 20 ft of sanitary sewer. Contractor: DIRTWORKS EXCAVATION Owner: BLAGDEN,MELISSA M 2221 SE 53RD AVE ZAREBABAKANDI,SHERVIN HILLSBORO,OR 97123 12188 SW MERESTONE ST TIGARD,OR 97223 PHONE: 503-753-7562 PHONE: FAX: FEES Quantity. Description Date Amount Y0 if Sanitary Sewer 05/02/2019 $62.54 Snevifiosi 1 12%State Surcharge- 05/02/2019 $8.70 Plumbing Type of Use: SF 10 ea Minimum Fee Adjustment- 05102/2019 $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: (c .C Ij l Ct 7.?• Call 503.639.4176 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. CITY OF TIGARD PLUMBING PERMIT " COMMUNITY DEVELOPMENT1111 Permit#: PLM2019 00185 TfGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 f, Date Issued: 05/02/2019 Parcel: 1 S134CC00900 Jurisdiction: Tigard Site address: 12180 SW MERESTONE CT Project: BLAGDEN Subdivision: MERESTONE Lot: 9 Project Description: Replacing 20 ft of sanitary sewer. Contractor: CLOG BUSTERS LLC Owner: BLAGDEN, MELISSA M 2900 SW CORNELIUS PASS RD, STE 549 ZAREBABAKANDI, SHERVIN HILLSBORO, OR 97123 12188 SW MERESTONE ST TIGARD, OR 97223 PHONE: 503-680-8947 PHONE: FAX: FEES Quantity Description Date Amount 20 If Sanitary Sewer 05/02/2019 $62.54 Specifics: 1 12%State Surcharge- 05/02/2019 $8.70 Plumbing 10 ea Minimum Fee Adjustment- 05/02/2019 $9.96 Type of Use: SF Class of Work: ALT Plumbing 45 Misc Administration Fee 05/15/2019 $45.00 Type of Const: Occupancy Grp: Stories: Total $126.20 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. Y. . a obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. 7------(raWb411101, Issued By: , Permittee Signature: "-". 410111 `� _h 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 o •• :" =ct. SII_. __ __.._. _. _ _. _.___ _. _._._ _ _. Approved plans are required on the job site at the time of each inspection. Doc uSigqn Envelop�Je ID:D69404C2-4325-41 D4-912D-OE1834E958CD DIAa 1 Gl Hill.liIJE.l11t:dLWU Site Utilities FOR OFFICE ('SE OwLv City of Tigard ��� Received Permit p liget 13125 SW Hall Blvd.,Tigard,OR 97223 DateBy: �/�,. >l Phone: 503.718.2439 Fax: 503.598.1964 Plan Review Date/By: Other Permit No.: Inspection Line: 503.639.4175 1AA nn q Ti G A R[} I1'I AY 1 � �l?! Date Ready/By: Aids: INSee Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information ilrevipair "E :G' r7 - ii'dn. 4�R'd. , .� S , } ya _, DWms' " 3_ ;� ; rl.. , tti.. ;. Ai 1 ti 1:41116X) „ 1For special information use checklist New construction Description I Qty. I Ea. 1 Total Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) E „rte _ + Q1 O ttW' f C Ip :GIS ` f. SFR(1)bath 312.70 -and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78 ❑Accessory building 0 Multi-family SFR(3)bath 500.32 Each additional bath/kitchen 25.02 ❑Master builder 0 Other: {rI� s�, za� ,� sa INEh- Fire sprinkler( sq.ft.) Paget B S RjOI!4 44 D . " I Site utilities: Y Catch basin or area drain 18.76 ` Job site address: 4 TJ© SIA/ ivi �eS e c Drywell,leach line,or trench drain 18.76 76 City/State/ZIP: Grd�/ ��Z Footing drain(no.linear ft.: ) Page 2 Suite/ 14g./apt-ri .,; I Project name: Manufactured home utilities 50.03 Cross street/directions to job site: 5 1/J [2.1 Pc V"C 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 ft.:_) Page 2 I Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: 0 q ( 97 1 Backflow preventer 31.27 1 d I� _ 4 f Backwater valve 12,51 II)c E .r , �,.gaff r 4_�: _t, ., O _ 3: :e.. �,� Clothes washer 25.02 PLM2019-00185 Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 ° ' © 4 ® t , '$, §" -1 ❑ � l } ,+= Expansion tank 12.51 Name: e11'5 S4 etGp Agri /syrcy'. in 9�1�'c'ljab/Tl�jhd� Fixture/sewer cap 25.02 Address: t 2)40 5w M�/re S'�n-e C- Floor drain/floor sinkmub 25.02 Garbage disposal 25.02 City/State/ZIP: Ti 3,A rc:) C7 L Z ' '�-2 f---S ,ill / �1,�7Y1e�- Hose bib 25.02. Phone:(L f l) 6LiS 0Zil€tl (aol) -5=-1.4 01.0 to 0 Ice maker 12.51 t HR 7lli:*'h IWrilq zt �HTp d � p Interceptor/grease trap 25.02 ,_,, ,a .: corrot rc PP4;mnw , ro-.. , ,€g,.«,-,s = Business name: Medical gas(value:$ ) Page 2 Primer 12.51 Contact name: ,/),e,.1 t s s( 5 146 /sr (YlRoof drain(commercial) 12.51 Address: 1 1 U 0 I.W Vie f e s C+- ._____"_______`-{ '411e1 1 Sink/basin/lavatory 25.02 City/State/ZIP: !l" � ) � /^ Q1,(2.- c 4--'2_2..� Solar units(potable water) 62.54 Phone:4-11) VL{S QjZg :(41.1'1) 3L.'1-1 cip(,0 Tub/shower/shower pan 12.51 E-mail: to a d e n - � pt yy l at 1 _ CO Urinal 25.02 yi 1 , in§ fi-aa d so e:e " Water closet 25.02 ,ii- i iiliF jEajM , rR u ,`:mai evr "kmi, Business name: Clog Busters LLC Water heater 37.52 Water piping/DWV 56.29 Address: 2900 SE Cornelius Pass Rd#549 Other: 25.02 City/State/ZIP: Hillsboro,OR 97123 Subtotal Phone:( 503)680-8947 Fax:( 503)530-8494 Minimum permit fee: $72.50 CCB Lie.:200212 Plumb',�r 4ePedir>' '383 Plan review (25%of permit fee) r-DocuSigned by: rY�- �1 •, f` � ��_,i o 11 State surcharge(12%of permit fee) Authorized signature( t LUS$A J it"r t't° TOTAL PERMIT FEE `-76c45C4uDa 9w .. s4510A1c1 F46A... This permit application expires if a permit is not obtained within 180 days Print name: Mel 1 sS3� Shervi n Dater/��/2019 B I asde n after it has been accepted as complete.. k I:1Building ennits\PLMU-Pe mztApp.doe 10101/09 440-4616T(10/02/COM/wEB) CITY OF TIGARD PLUMBING PERMIT ' I COMMUNITY DEVELOPMENT Permit#: PLM2019-00185 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/02/2019 T-1(;A R p g Parcel: 1 S134CC00900 Jurisdiction: Tigard Site address: 12180 SW MERESTONE CT Project: BLAGDEN Subdivision: MERESTONE Lot: 9 Project Description: Replacing 20 ft of sanitary sewer. Contractor: DIRTWORKS EXCAVATION Owner: BLAGDEN, MELISSA M 2221 SE 53RD AVE ZAREBABAKANDI, SHERVIN HILLSBORO, OR 97123 12188 SW MERESTONE ST TIGARD, OR 97223 PHONE: 503-753-7562 PHONE: FAX: FEES Quantity Description Date Amount 20 If Sanitary Sewer 05/02/2019 $62.54 Specifics: 1 12%State Surcharge- 05/02/2019 $8.70 Plumbing Type of Use: SF 10 ea Minimum Fee Adjustment- 05/02/2019 $9.96 Class of Work: ALT Plumbing 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: • Zeir// a75c."' 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 Fixtures City of Tigard = Received f, ��a�t�/(� //'' INele 13125 SW Hall Blvd.,Tigard,OR 97223 Dan Re ��/ � �Du��� Phone: 503.718.2439 Fax: 503.598.1960 Plan Review Date/By: Other Permit No.: 1 , v 1/i Inspection Line: 503.639.4175 �' ) Date Ready/By: Jur is to See Page 2 for Internet: www.tigard-or.gov Notified/Method. Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑New construction 0 Demolition For special information use checklist Description I Qty. I Ea. I Total ❑Addition/alteration/replacement ®Other:Emergency Se 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 0 Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 ❑Accessory building 0 Multi-family Each additional bath/kitchen 25.02 ❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address:12180 SW Merestone Ct Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP:Tigard OR Footing drain(no.linear ft.:_) Page 2 Suite/bldg./apt.no.: I Project name:Blagden Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:12) 20 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.: 1S134CC00900 Backflow preventer 31.27 Backwater valve 12.51 a )SES. I'. ION OF.t ORK Clothes washer 25.02 Emergency Sewer Repair Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 ,t ( **AO O OWN R I 0 MOT Expansion tank 12.51 Name:Melissa Blagden&Shervin Zarebabakandi Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address:12180 SW Merestone Court Garbage disposal 25.02 City/State/ZIP:Tigard OR Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 ', 441:,I,.CANT.,,� , _ 0 CONTACT PERSON Interceptor/grease trap 25.02 Business name:Dirtworks Excavation LLC Medical gas(value:$ ) Page 2 Primer 12.51 Contact name:Bobbie Joe Dorton,Jr Roof drain(commercial) 12.51 Address:2221 SE 53rd Avenue Sink/basin/lavatory 25.02 City/State/ZIP:Hillsboro OR 97123 Solar units(potable water) 62.54 Phone:(503)753-7562 Fax::( ) Tub/shower/shower pan 12.51 E-mail:dortons@icloud.com Urinal 25.02 25.02 _Water closet .�,>,.-a-- ,K M. ::;e.OM T$4.4.k,- < r ,...,„,,,„ ,,.,.,„,-`,K .,.�,» 37.52 Water heater Business name:Dirtworks Excavation LLC Water piping/DWV 56.29 Address:2221 SE 53rd Avenue Other: 25.02 City/State/ZIP:Hillsboro OR 97123 Subtotal Phone:(503)753-7562 Fax:( ) Minimum permit fee: $72.50 72.50 Plan review (25%of permit fee) CCB Lic-:220245 Plumbing Lie.no.: /% _ State surcharge(12%of permit fee) 8.70 Authorized signet-re: " TOTAL PERMIT FEE 81.20 Print name:Bobbi:Joe Dorton,Jr. Date:5/1/19 This permit application expires if a permit Is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB) City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 Location: Inspection Date: 12180 SW MERESTONE CT, TIGARD, OR, 97223 Record Type: Record ID: Residential - Plumbing PLM2019-00185 Inspection Type: Inspector: 399 Plumbing final Don Sylvester Result: PASS - NoCofO Comments: Violation Summary: Inspector Contractor