Permit CITY OF TIGARD PLUMBING PERMIT
sa COMMUNITY DEVELOPMENT Permit #: PLM2010 -00116
T 1G;kkp 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/16/2010
Parcel: 2S102AD01400
Jurisdiction: Tigard
Site address: 9079 SW BURNHAM ST
Subdivision: Lot: 0
Project: Burnham Street Improvements
Project Description: Relocate irrigation backflow device.
Owner: FEES
HENDERSON, JACK R & MARY S Quantity Description Date Amount
9075 SW BURNHAM ST
TIGARD, OR 97223 1 ea Backflow Preventer 04/16/2010 $31.27
PHONE: 1 12% State Surcharge - 04/16/2010 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 04/16/2010 $41.23
Contractor: Plumbing
KODIAK PACIFIC CONSTRUCTION
PO BOX 886
TUALATIN, OR 97062 -0886
PHONE: 503 - 783 -4300
FAX: 503- 682 -3777
Type of Use: COM
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 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246,6699 or 1.800.332.2344.
Issued By: Permittee Signature:
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.
Plumbing Permit Application .
Building Fixtures REcEi ` FOR OFFICE USE ONLY
City g % /�O • / of Tigard [ 2Q Received /, / permit No.: O ' �y�Q /Q -
W / /tCJ
13125 SW Hall Blvd., Tigard, OR 97223 5 APR 1 Date/By: /
Plan Review
e Phone: 503.639.4171 Fax: 503.598.1960 ^� �± ra Date/By: Other Permit No.:
Inspection Line: 503.639.4175 CITY OF 1 IGAR( Date Ready/By: 1u � See Page 2 for
1 1 �� It I7 Internet: www.tigard -or.gov f� Notified/Method: l Supplemental Information
BUILDING DIVIStc. -
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 Total
❑ 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 ❑ Commercial/industrial
SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
D', 9 $ 6 1, f � ,1 Catch basin or area drain 18.76
Job site address: I
'lab Drywell, leach line, or trench drain 18.76
City /State /ZIP: j egq %� 0 9 722 3 Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: �� Project name: 3 u rn A, _ v . 5 ', ,l p re, V ".0 e-n Manufactured home utilities 50.03
Cross street/directions to job site: 7 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:
Backflow preventer / 31.27
Tax map /parcel no.:
Backwater valve 12.51
DESCRIPTION OF WORK 25.02
J Clothes washer
Rt \acaltt, ..l- rrt eilo -t b e kk low do vv c b e I, . � Gi Dishwasher 25.02
PltLA.) S1e,'P4t1 Drinking fountain 25.02
Ejectors /sump 25.02
,TFROPERTY OWNER I ❑ TENANT Expansion tank 12.51
`� Fixture /sewer cap 25.02
Name: i-‘ .� », e cal e 7"( - 01) e'+r .51 Floor drain/floor sink/hub 25.02
Address: C )'o ' ? - 9 5t....) BO. 1 in.zoil Garbage disposal 25.02
City/State /ZIP: -FT „ Op._ 9 7 2.2 Hose bib 25.02
Phone: ( ) J Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Business name:
Primer 12.51
Contact name: Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
Urinal 25.02
E -mail: 25.02
Water closet
CONTRACTOR Water heater 37.52
Business name: ko p/4 K ,P4c /F/t. CoMS7u(Pc Water piping/DWV 56.29
Address: po K E38G Other: 1 25.02
City /State /ZIP: - 17A, t A'r n/1 ) Fa. 9 7 0 (O 2 Subtotal
Minimum permit fee: $72.50 1 a .50
Phone: (SOS) - 7 61 - 4 io Q Fax: (SV.3) 6., U q 7 7 ,
PI Plan review (25% of permit fee) -�-
CCB Lic.: 5 ? 5'3 3 Plumbing Lic. no.: 34 - 47/ PI State surcharge (12% of permit fee) S. 10
Authorized signature: TOTAL PERMIT FEE g i . 0
This permit application expires if a permit is not obtained within 180 days /
Print name: �Q y (� Rp J Date: /�� l� p after it has been accepted as complete. v
*Fee methodology set by Tri-County Building Industry Service Board.
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