Permit i
II .Q CITY OF TIGARD PLUMBING PERMIT
: : :. COMMUNITY DEVELOPMENT Permit #: PLM2009-00115
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 05/12/2009
Parcel: 1S135DC06300
Jurisdiction: Tigard
Site address: 11595 SW GREENBURG RD
Subdivision: Lot: 0
Project: Vanwormer
Project Description: Replace 60 feet of sanitary sewer.
Owner: FEES
VANWORMER, IDA M Quantity Description Date Amount
22005 NW RUSSELL CREEK RD 100 If Water Service 05/12/2009 $55.00
YAMHILL, OR 97148 1 12% State Surcharge - 05/12/2009 $8.70
PHONE:
Plumbing
18 ea Minimum Fee Adjustment 05/12/2009 $17.50
Contractor: - Plumbing
MALLARD PLUMBING COMPANY
17011 SE TENEYCK
SANDY, OR 97055
PHONE: 503 - 593 -7878
FAX: 503 - 668 -7325
Type of Use:
Class of Work: 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
Issued By kil �,.. n Q n n (� Permittee Signature: r 0 le I ` _1111 ,( ,
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 F ay OFFICE i ONLY
City of Tigard d Received n,i
DatelBy: O OQ ,_A Penrit N°: 92- ��e COO I 1
a 13125 SW Hall Blvd., Tigard RY97 009 p •
Phone: 503.639.4171 Fax: 61.598" 1 • .1 tan Revie4v
DatelB,y: Other Permit No.:
TI GAIC'D I nspection Line: 503.639.4 75
Date Ready/By: J i 0 See Page Z far
Internet: www.tigard- or.goy. T GF TIG�,ARD Notified/Method: ,C
TYPE�.4l�(1FOIt;�J'Vf ( 7 Supplemental Information
•
FEE* SCHEDULE
❑ New construction ❑ Demolition For special infornuuion use checklist
V Addition /alteration/replacement ❑ Other Description ■ty. Ea_ Total
New I- 2- family dwellings (includes 100 ft_ for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249,20
g I- and 2- family dwelling ' ❑ Commercial/industrial SFR (2) bath 350.00
1=1 Accessory building r ❑ Multi- family SFR (3) bath
1 399 -00
El Master builder ❑Other: Each additional bath/kitchen 45.00
JOB SITE INFORMATION AND LOCATION Fire sprinkler ( s4- n) Page 2
Site utilities
Job site address: 1 1 • 5 J'( G.t.r.^� l /� C atch basin or area drain
tr. -3,� 16.60
City/State/ZIP: c �� ` Og i Drywell, leach line, or trench drain 16.60 '
7
Footing drain (no. linear 11.: ) Page 2
SuitelbldgJapt_ no.: Project name:
Cross streetr'direetions to job site: Manufactured home utilities 110.00
- Manholes 16.60
Rain drain connector 16.60
Sanitar sewer (no. linear R.: 4 0) / Pace 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Lot no.: Water service (no. linear R.: ) P age 2
Tax map /parcel no.: Fixture or item
Absorption valve 16.60
DESCRIPTION OF WORK
Backflow preventer Page 2
�j
/ e
l! lAt� gel S 4 t ,, --S Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
❑ PROPERTY OWNER El TENANT Dnnlangfountain • 16.60
Name: Ejectors/sump 16.60
Expansion tank 16.60
Address:
Fixturelsewcr cap 16.60 •
City /State/ZIP: Floor drain/floor sink/hub 16.60
Phone: ( ) Fax: ( ) Garbage disposal 16.60 t
y APPLICA.NT 0 CONTACT PERSON Hose bib - 16.60
• Business name: /Via ,,,,,1 Ice maker 16.60
' Interceptor /grease trap 16.60 I
�� r
Contact name:
e-• RQ tON // Medical gas (value: $ ) Page 2
Address: / '7U I i S6 ' '7 el ck (a(_ Primer 16.60
City /State/ZIP: SA wa f Ore / 9 7 Ss Roof drain (commercial) 1660
Phone: (5°3) V43- 7 8 Fax: ' ( 503) (4'$ 7325 Sink/basin/lavatory 16.60
P r n. , y � 52 � t oa' C d Tub/shower/shower pan 16.60
E-mail: MA 114, t.a..
jJ Urinal 16.60
CONTRACTOR Water closet 16.60
Business name: av , / / y Water heater 16.60
Address: 76 I I . _re Teo) e yc t e Other
!
City/State/ZIP: 9 � ` a � ✓ ! G` 7 Subtot
-
5
Phone: ( -S;'? ) ax: Minimum permit fee: $72 -50
S93 7 7 F ($o 3 )4-(08 -7 ,7z5 R esiden tialbackflowminimumpermitfee: $36.25
•
CCB Lie.: / -7 ?3 9.a • Plumbing Lie- no.: pg 2 2 7 y Plan review (25% of permit fcc)
Authorized signature: - 7 • \ • 1 1
State surcharge (12% of permit fee)
TOTAL PERMIT FEE
Print name: 41 g� I Date: 518/0 ? This permit application expires if a permit is not obtained within
e ((( 1110 days after it has been accepted as complete.
'Fee methodology set by Tri -County Building Industry Service B
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