Permit CITY OF TIGARD PLUMBING PERMIT
IIII �" COMMUNITY DEVELOPMENT Permit#: PLM2020 00124
T f3 Aft ) 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/19/2020
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Parcel: 1 S 133DC09400
Jurisdiction: Tigard
Site address: 13195 SW SHORE DR
Project: MONTGOMERY Subdivision: WINTER LAKE Lot: 22
Project Description: Backflow preventer for landscape irrigation.
Contractor: EASDALE BACKFLOW& IRRIGATION Owner: MONTGOMERY, ROY L JR & BRENDA L
PO BOX 4211 13195 SW SHORE DR
WILSONVILLE, OR 97070 TIGARD, OR 97223
PHONE: 541-926-8119 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 03/19/2020 $31.27
Specifics: 1 12%State Surcharge- 03/19/2020 $8.70
Plumbing
41 ea Minimum Fee Adjustment- 03/19/2020 $41.23
Type of Use: SF Plumbing
Class of Work: OTR
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.
Plumbing Permit Application r
Site Utilities ° �.C.�,t,1 E� FOR (iFFICI' 1 ,1 Oy1-1
City of Tigard h 1 S Z020Y Permit No.:
i 13125 SW Hall Blvd.,Tigard,OR 97223() Plan Rcvic..,
a Phone: 503.718.2439 Fax: 503.598.1960 r p® yamiBy. Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 .1 '( tjb'^ �t7^il Ready/By: hots: ®See Page T for
, Internet www.tigard-or.goe t°.*F1�51?-A 1r1 otifred/Mcthod: Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For specie informetiort ese checklist
Description I Qty. 1 Ea 1 Total
❑Addition/alteration/replacement ❑Other: New I-2-family dwellings(mcludes 100 R.for each utility connection)
CATEGORY OF CONSTRUCTION • SFR(1)bath 312.70
K1-and 2-family dwelling ElCommercial/industrial SFR(2)bath 437.78
SEl Accessory building El Multi-family
ac E (3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder ❑Other:
Fire sprinkler( sq.it) Page 2
JOB SITE INFORMATION AND LOCATION Site irtBitiea:
Job site address: I'j Inc" S.4A/. .5%c t 2.-. Q)r
Catch basin or area drain 18.76
WZTP: l( OV. `1� ..3 Dry well,leach line,or trench drainage 6
City/Sta
7 N''c� a Footing dram(no.linear R.: 1 Page 2
Suitelbldglapt no.: I Project name:
Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
•
W\ .Or.S.V . Rain drain connector 18.76 .
Sanitary sewer(no.linear fL:_) Page 2
Storm sewer(no.linear$:_) Page 2
Water service(no.linear ft: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow pm-venter I 3127 31.4'1
$S`lfiP1'!ON OF WORK • Backwater valve 12.51- Clothes washer 25.02
r;"►4�r 5'f ✓ v Dishwasher 25.02
/ Drinking fountain 25.02
Ejectors/sump 25.02
st PROPERTY OWNER D TENANT' Expansion tank 12.51
Name: j)"9 - - Fixture/sewer cap 25.02
rile
Address: _ G$}D A+(I /� Floor demn/floor sitar/hub 25.02
i� y S'4.. "tt°l . OV". Garbage disposal 25.02
City/State/ZIP: ,t.,w,'a 0/Z Ft�aJ) Hose bib 25A2
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT 0 CONTACT PERSON Intereeptor/grease nap 25.02
Business name: Medical gas(value:$ ) Page 2
Printer 1251
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 6254
Phone:( ) Fax::( ) Tub/ahoweeshower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
y �� Water beater 37.52
Business name: C..A.5�,Y� 1�,.K,I,i�I . 'J"t `^ .v.tr t Water PP g�r n W V 56.29
Address: -P.0 0 a< Y1.-11 Other: 25.02
City/State/ZIP: w ,lyt,..1. - 00` y'11J1.)p Subtotal Yr,atil
re Minimum permit fee: $7250
Phone:(ty-by) "�ti 'S�r{ Fax:( )
CCB Lie.: 'n IT) t_C S Plumbing Lie.no.: Plan review'(25%of permit fee)
State surcharge(12%of permit fee) 1�
Authorized signature: TOTAL PERMIT FEE %Z so
Print nark• Date:/. 14.-a0 TLir permit application expires if a permit is ant obtalaed within 188 days
r it
been
cepted se complete.
*Fee methodologygy set by Tri-Corat Building India Service Board.
ty 8 Industry
I.Moilding\Permits 1PLMU-Permatppdoe 10/0IM' 4404616T(I0,02/COMIWBB)