Permit CITY OF TIGARD PLUMBING PERMIT
ii
111111 COMMUNITY DEVELOPMENT Permit #: PLM2009 -00228
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/19/2009
Parcel: 1 S134CCO3200
Jurisdiction: Tigard
Site address: 12000 SW 122ND CT
Subdivision: YE OLDE WINDMILL Lot: 18
Project: Osbo
Project Description: Replace 40' of water service.
Owner: FEES
OSBO, JAN D Quantity Description Date Amount
12000 SW 122ND CT
TIGARD, OR 97223 40 If Water Service 08/19/2009 $55.00
PHONE: 503 524 - 3505 1 12% State Surcharge - 08/19/2009 $8.70
Plumbing
18 ea Minimum Fee Adjustment - 08/19/2009 $17.50
Contractor:
Plumbing
JACK HOWK PLUMBING /RESCUE ROOTER
P.O. BOX 2830
CLACKAMAS, OR 97015
PHONE: 503 - 850 -3100
FAX: 503 - 491 -2932
Type of Use: SF
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: �i((��// Permittee Signature: 0 Az /C'�7.70/\ 1
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.
I Approved plans are required on the job site at the time of each inspection.
JAN -17 -2005 15:55 P.001
• • Plumbing Permit Application
Building Fixtures EC EI V E FOR OFrlc r USE ciNI,V
City of Tigard Ef p O:I� I 13125 S�' Hall Blvd.. Tigard, OR 97::23 All 1 7 2009
Phone: 503 639.4171 Fax: 503.598.1 X160 Data l3� Other Feting Na
Tic ;ARn
Inspection Line. 503 639 41 7 CITY OF TIGARD Dnr�Rcad; B o rs "
Intcmet: wwvs tigard- or,gov > Su See muse i Information
I, .� r , 3N � "NMtfed�NlcEhad
G Su plemcntal tnforraaeion
TYPE OF' WORK FEE* SC EDULE
i ❑ Now construction _ ❑ Demolition For v ecialin ormatiun use cl(ecllist.
Desert . tom 011111EIMI Total
/+ AdditionJalteratiort 'replacement [I Other: New I- 2- family dwellings (includes 100 ft. for each mil* connections
CATEGORY OF CONSTRUCTION SFR t I 1 bath 249 20
pcI- and 2- family dwelling Q Commercial /industrial - SFR 121 bath 150.00
12 Accessory building Er Mufti-family SFR 131 bath 390.00
El Muster builder ❑ Other Each additional bath /kitchen 45 00
Fire sprinkler( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities
Job site address: ` t9p 5' — "
Catch basin or area drain 16,60
f-'it) /State /ZIP: , � - 7.,-3.3--- � Drywcll, leach line, or trench drain 16.60 -
Suite /bldg /apt. 00.; Project numc; & Air'. Footing drain (no. uncurl.. f1.. �1 rage 2
Cross street/directions to job site: Manufactured home utilities 110.00
- Manholes 16.60
-• Rain drain connector 16.60
Sanitary sewer (no. linear IZ,; �1 Page 2
Storm sewer (no. linear ft.: _) Page 2 __
Subdivision Lot. no,: Water service (no. linear ft.: 4 page
Tar map parcel no,:
Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK Backflow preventer Page jam aek g e 2
./ Backwater valve 16 60
/ le Clothes washer 16.60
Dishwasher 16.60
r"R OWNER I El TENANT Drinking fountain 16.61)
Name: /,
. Ejectors /sump 16,60
. Expansion tank 16.60
Address: /1) 5 - _
1st Fixture / se w -er cap 16.60
City /Stuto /ZIP: r//M Floor drain /floor sink/hub 1 6,60
Phone: ( 33j „5 � Fax: ( ) Garbage disposal _ 16.60
►AP1'1 „ICANT [] CON PACT PERSON Hose bib - _ 16,60
Business name: ARS dhn JACK HO�� 1 / -Ice maker 16.60
_ Rescue Rooter _ T Interceptor/grease trap 16.60
Contact name: JOYCE DENNIS Medical gas (value: $ ) Page 2
b
Address: P.O. BOX 2830 Primer ` 16.60
City /State/ZIP: CLACK.AMA5, OR 97015 Roof drain (commercial) 16.60
Phone: , - . +I' — . ( Pax; ; (503) 491.2932 Sink/basin/lavatory 16.60
+
E -mail: JO$'CEGp
•
Tub /shower /shower pan 16.60
• _ Urinal 16.60
CONTRACTOR W'aler closet 16.60
Business name: ARS dba JACK HOWK /Rescue water heater _ 16.60
Address: Y.O. BOX 2830 Other: —”
City /State/ZIP: CLACKAMAS, OR 97015 _ — Subtotal T
Phone: t D /1 P ax; (503)491-2932 Minimum permit toe: $72.50
Ea EIMEMIIMIMIIIIII � � � Residential ba[;kflow minimum permit fee: $36.25 r hunbing Lie. no.: 34 -168 P Plan review (25% of permit fee)
Authorized signature: en State surcharge (12% of permit fee) Mgr
\ , 1+C/ TOTAL PERMIT FEEL
/.' Print name: 1r ' OP - Date: % A This permit application expires if a permit is not obt: n ,i■ (( v
180 days after It has been accepted as eompi
�� ~T -491 -2932 *Pee meth odology set by Tri County Building Industry Service Board.
�.laudding \Pcr,n�,a('L rr -r
P lease FAX '3.ACK tc}c
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JAN -17 -2005 15:55 P.002
' Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qt,. Fee (ea) Total Square Footag: Permit Fee:
Footing drain • 1" 100' 55.00 0 to 2.000 SI 15.00
Footing drain - cacti additional 100' 46.40 2.041 (0 3,640) $I60.00 -
3.601 to 7,200 $220 00
Sewer - 1st 100 . 55.00 7,201 and greater $309.00 -
Sewer - each additional 100 46.40
Water Seri, ice - 1st 100' lief( ' 55.00 - ,"
Medical Gas Systems:
Medical Gas Systems:
Water Seri. ice - each additional 100' 46.40 Valuation: Permit Fee:
storm & Rain Drain - 1st 100' 55.01)
$1 00 to $5,000.00 Minimum Ice $72 50
Storm & Rain Drain - each additional 100 46,40 $5.001.0(1 to $10,000 00 572 50 for the first S5.000.00 and $1 52 for each
Q ty. Fee (ea) Total additional $100 i)0 or fraction thereof. to and
Fixture or Item including $10.000.00,
Commercial Back Flow Pro ention Device 46.40 $10,001.00 to 525,1)1)0.01) 5148.50 for the first S10.000.00 and S1.5.1 for
Residential liackfloa Prevention Device each additional $100.00 or fraction thereof, to
(minimum permit fee 436,251 27.55 and including $25.000,00,
Rain Drain, single family dwelling 65.25 $25,001.00 to $50000.00 $379.50 for the first 525.00000 and $1 45 fix
each additional S 100.00 or fraction thereof. to
Inspection ofex[sling plumbing or and including 550.000,00.
specially requested inspections - per hour 72.50 and up $742.00 for the first $50.000.00 and $1,20 for Subtotal: i each additional $100.00) or fraction thereof.
Commercial Fixture Work: Plan Review for Plumb
lumbing Installations
Arc you capping, adding or replacing fixtures? if "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and
Q uantity Fixture W ork Performed greater. except systems designed and stamped by licensed
Fixture Type: Wiliam engineer.
Previous Capped - Added . >r aL9t)nQ ❑ New exterior plumbing site utilities for any complex structure
Baptistry /Font as defined in 0AR918- 780 -0040.
Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities.
- Jacuzzi/whirlpool ❑ Any multipurpose tire sprinkler System.
Car Wash -Each Stall - ❑ Any complex structure as defined in 0AR918- 780 -0040.
-Drive Thru _
Cuspidor/Water As Submit 2 sets of plans with any of the above.
Dishwasher - Commercial
- Domestic
Drinking Fountain Isometric or Riser Diagra _
Eve Wash _ ❑ isometric or riser diagram is required for new buildings
Floor Drain/sink -2 " that meet the qualifications above.
- 3•
- 4 ,
Car Wash Drain
Garbage - Domestic _ - Comments regarding fixture work:
Disposal - Commercial
- Industrial
-
Ice Mach. /Rettig. Drains - _ -
Oil $epurator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang -- -- --
- Stall
Sink -Bar /Lavatory
- Bradley *Note: If the fixture work under this permit results in an
- Commercial increase of sewer EDUs, a sewer permit will be issued and
- Service fees assessed for the sewer increase must be paid before the -
Swimming Pool Filter
Washer - Clothes plumbing permit can be issued.
Water Extractor
Water Closet - Toilet
-
Urinal
1 Other Fixtures:
i WuI Iding∎Permiir\PLM.PermiiApp.dac 12/27(06