Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2009 -00324
Date Issued: 11/04/2009
TIG ARD" 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Parcel: 1S134ACO2608
Jurisdiction: Tigard
Site address: 11335 SW COTTONWOOD LN
Subdivision: Lot: 0
Project: Skidmore
Project Description: Replace dishwasher, garbage disposal, add icemaker and new washer hookup
Owner: FEES
SKIDMORE Quantity Description Date Amount
11335 SW COTTONWOOD LN
TIGARD, OR 97223 1 ea Clothes Washer 11/04/2009 $25.02
1 ea Dishwasher 11/04/2009 $25.02
PHONE: 1 ea Garbage Disposal 11/04/2009 $25.02
1 ea Ice Maker 11/04/2009 $12.51
Contractor: 1 12% State Surcharge - 11/04/2009 $10.51
RAYBORN'S PLUMBING INC Plumbing
PO BOX 69
TUALATIN, OR 97062
PHONE: 503 - 692 -4139
FAX: 503 - 691 -2328
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $98.08
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: �p Permittee Signature:
4/1/ �f 4/ C . 7-70/./ r
CJ Ca11�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.
-503 691 2328 Rayborns Plumbing Plumbing a.m. 11 -03 -2009 1 /2
1 � ED
Plumb� Permit Applicatlbh
E CEI r
Building Fixtures NOV 0 3 200 fON OFFICE USE: (,N,.,
City of Tigard Received
ll Date/By: /// c .�► ' Permit No C/1,20091 Q 03 9 ,y
• 13125 SW Hall Blvd., "Tigard TIGARD
, OR 9 OF r , �
Q Phone: 503.639.4171 Fax: MIMING DIVI SI; � I�I Plan Revie
Date /By: Other Permit No..
Inspection Line: 503
T I G A K L) Date Ready /By: 6d See Page 2 for
Internet: www.tigard - orgov Notified/Method: / V tpplementallnformation
TYPE OF :WO •Sa LE t
❑ New construction ❑ Demolition For special information use checklist
Description J Qty. 1 Ea. 1 Total
® Addition/alteration/replacement ❑ Other: New 1- 2-family dwellings (includes 100 ft. for each utility connection)
4,,: CATEGORY_ OP_ CONStRI)C`rloAt _ ;,i -. SFR (1) bath 312.70
® I- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi- family SFR (3) bath 500.32
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other:
Fire sprinkler ( sq. fr.) Page 2
"" JOB SITE 'INFORMATION, AND LOCATION • :I, • • Site utilities:
Job site address: 11335 SW Cottonwood Lane Catch basin or area drain 18.76
City/State /ZIP: Tigard, OR 97223 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear It.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Skidmore Manufactured home utilities 50.03
Cross street/directions to job site: 655 C2 Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (nu. linear ft.: Page 2
Stonn sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ___) Page 2
Subdivision: I Lot no.: Fixture or item:
fax map /parcel no.: Backfow preventer 31.27
_ DE$GRIPTION OF N+ORK Backwater valve 12.51
' ' ' :' Clothes washer I 25.02 25.02
Replace Dishwasher, Disposer, add Icemaker
Dishwasher 1 25.02 25.02
New Utility Washer Hookup Drinking fountain 25.02
Ejectors/sump 25.02
... .®'PR(pOtTY OWNER - ' 0 TENANT Expansion tank 12.51
Name: Skidmore Fixture/sewer cap 25.02
Floor drain/flour sink/hub 25.02
Address: 11335 SW Cottonwood Lane
Garbage disposal I 25.02 25.02
City/State /ZIP: Tigard, OR 97223 Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 1 12.51 25.02
Interceptor/grease tra
,_ .:: Y!' �IPPLECAhP1 _ _ - , , : 0 ,CO NTACT. PF.It,SOfll` �; c trap 25.02
Business name: Medical gas (value: $ ) Page 2
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
E -mail: Urinal 25.02
Water closet 25.02
• CONTRACTOR -
"' Water heater 37.52
Business name: Rayborn's Plumbing loc Water piping DWV 56.29
Address: P.O. Box 69 Other: 25.02 -
City/State /ZIP: Tualatin OR 97062 Subtotal , JA9:98
Phone: (503) 692 -4139 Fax: (503) 691 -2328 Minimum permit fee: 572.50 ,n, 57
,A�CB Lic.: 87852 ✓ Plumbing Lic. no.: 34 -166PB ✓ / Plan review (25% of permit fee) (Q , 5 /
�J v State surcharge (12% of permit fee) .- T '
Authorized signature: TOTAL PERMIT FEE 0
Print name: Kenneth A. Provancher Date: 11/3/09 Thia permit application expires if a permit is not obtained within 80 days
after it has been accepted as complete. r 0 r ✓
*Fee methodology set by Tri- County Building Industry Service a
1 Building `Permi:s'PLMU.PerrmApp.dec 10 /04 440- 46I6T(IO'02 /COw'WEB)