Permit •
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT
Permit #: PLM2009 -00237
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/28/2009
Parcel: 2S 103AB06400
Jurisdiction: Tigard
Site address: 12393 SW 114TH TER
Subdivision: WALNUT GLEN Lot: 22
Project: Nguyen /Pham
Project Description: Install residential backflow preventer for irrigation system.
Owner: FEES
NGUYEN, QUANG V & Quantity Description Date Amount
PHAM, ANN X, 12393 SW 114TH TER
TIGARD, OR 97223 1 ea Backflow Prevention - RES 08/28/2009 $27.55
PHONE: 1 12% State Surcharge - 08/28/2009 $4.35
Plumbing
9 ea Minimum Fee Adjustment - 08/28/2009 $8.70
Plumbing
Contractor:
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: OTR Type of Const:
Occupancy Grp:
Stories:
Total $40.60
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 Notifir:atinn 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 dire questions to SUNG - ..fling +3.246.6699 or 1.800.332.2344.
lss d By: • `/ o f Permittee Signature: K
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 FOR OFFICE USE 011.\
City of Tigard sy �� D 9 Permit No.: IG/�Ji ! w j�/„a, 37
. 13125 SW Hall Blvd., Tigard, OR 97223 `
IN
Phone: 503.639.4171 Fax: 503.598.1960 Plan Review
- Date/By: Other Permit No.:
T 1 G A R D Inspection Line: 503.639.4175 Date Ready /By: Juris: ® 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: New 1- 2-family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family SFR (3) bath 399.00
❑ Master builder Each additional bath/kitchen 45.00
❑ Other:
Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: ( Z ;el 3 .i/k) 1 L. '1„h Tr n'aC5 Catch basin or area drain 16.60
City/State /ZIP: '( y rcl R 1 722 3 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Project name: Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
o mina 4- 4 II 9 itr rtce. Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: I Lot Water service (no. linear ft.: Page 2
Fixture or item
Tax map /parcel no.: Absorption valve 16.60
/ DESCRIPTION OF WORK Backflow preventer / Page 2
•
i rri c{+ 01i / SprinkJ r ..C./. m Backwater valve 16.60
JJ ((( (( Clothes washer 16.60
Dishwasher 16.60
a PROPERTY OWNER f ❑ TENANT Drinking fountain 16.60
Ejectors /sump 16.60
Name: 0 (1c n G1 N 91.1 yr/ *Yr) Ph a m Expansion tank 16.60
Address: I 9 514 1 I t f b T- i i ct Fixture /sewer cap 16.60
City/State /ZIP: r c1 0R 4 1 7 Floor drain/floor sink/hub 16.60
( 5 03) 3i,45940/(314)) J eo Garbage disposal 16.60
Phone: ` Fax: ( )
❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60
Ice maker 16,60
Business name:
Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State /ZIP: Roof drain (commercial) 16.60
Phone: ( ) Fax: ( ) Sink/basin/lavatory 16.60
E -mail: Tub /shower /shower pan 16.60
Urinal 16.60
CONTRACTOR Water closet 16.60
Business name:
0 tk.)t) �a Water heater 16.60
Address: � Other:
City/State /ZIP:
Subtotal
Minimum permit fee: $72.50 / a5
Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 (� '
CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) -6--'
State surcharge (12% of permit fee) 5/. TOTAL PERMIT FEE 7 3 S
Authorized signature: y � 1 / /n, ea 0
Print name: d t o N _pH AM Date: /) rild (c7 This permit application expires if a permit is not obtained within
/ , l 180 days after it has been accepted as complete.
*Fee methodology set by Tri- County_ Building Industry Service Board.
I:\ Building1Pemrits \PLMF- PennitApp.doc 12/27/06 440- 4616T(10/02/cOM/WEB)