Permit CITY OF TIGARD PLUMBING PERMIT
`g '! COMMUNITY DEVELOPMENT Permit #: PLM2012 -00010
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/17/2012
Parcel: 25111 BD00406
Jurisdiction: Tigard
Site address: 9675 SW MARILYN CT
Project: Fannie Mae Subdivision: DARMEL NO.3 Lot: 27
Project Description: Connecting existing house to sewer. Reimbursement district fees paid.
Contractor: SOIL SOLUTIONS Owner: FEDERAL NATIONAL MORTGAGE ASSN
3540 SE 28TH AVE BY RECONTRUST CO
PORTLAND, OR 97202 400 NATIONAL WAY
SIMI VALLEY, CA 93065
PHONE: 503 - 234 -2118 PHONE:
FAX: 503 - 331 -7133
FEES
Quantity Description Date Amount
75 If Sewer Service 01/17/2012 $62.54
Specifics: 1 12% State Surcharge - 01/17/2012 $8.70
Plumbing
Type of Use SF 10 ea Minimum Fee Adjustment - 01/17/2012 $9.96
Plumbing
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 -0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.. . - •
Issued By: G Permittee Signature:
Cal - "• . • ..175 by 7:00 a.m. for the next available inspection date.
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.
From:Soil Solutions 503 331 7133 01/11/2012 11:43 1#026 P.001/003
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Application i
Plumbing Permit A
P ti � ol< t)Fl 11 t 1 :sl ()NI l
City of Tigard ^( �, ' . Received
13125 SW Hall Blvd., Tigard, OR 97223 ' v ' Q �� • sr ,� t
Phone: 503.639.4171 Fax: 503.598.1464 \� ~ Plan Review Other Permit No.:
24- Hour Inspection Line: 503.639.4175 '' C l . ,1 � I• Date By: a ter - �, oce
Internet www c! ttgard.or us �" Q~ �' Date i i y/By 7u s; I e 2 far
• , -. ., �v! Supplemental N e i j '
TYPE OF WOE . s9 FEE *. SCHEDULE.
❑ New construction 0. i ' lition , ; , , Ea.
`� �� a Total
• Addition/alteration/replacement ❑
;
New 1- 2-famity dwellings (includes 100 ft. for each utility connection) ,
? CATEGORY , OF C ONSIRUCIION !
,r 1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi - family • t
❑ Master builder ❑ Other: t t
JOB SITE ;INFORMATION AND LOCATION;;
Fire sprinkler ( sq. ft) Page 2
Job site address: Ct , 510 ,M o2 ,.. r+
1 1 l �Ji' ■ .. t
City /State /ZIP: t l , 0 cq a r ( r s '
Suite bldg, /apt. no.: V I Project name: ` ' ' Page 2
Cross street/directions to job site: SCO a — A t !!
ManlIOMS .t .
• Rain drain connector .t
Subdivision: • ' Lot no.: / 1 '
Fixture or item
Tax map /parcel no.:
Absorption valve 16.60
�rLAJL It ►Oa ► _. _ '�i� tom_ i A ■�* 1
g - MPH" ► 1.111 ( I p ,1,,� ■' ^ .
Clothes 16.60 0
4�'L'I e O (Ux . (CI 5 `A, 1 M `-!l� Dishwasher 16.60
!§ PROPERTY OWNER `+ 16.60
(/Z _ .. 16.60
Name:
nn i st cf. I�1Qi ui�r, �Z'G�LI CI t,
�o e'1) x <1 0 &� 16.60
Address: . I
�•� �/
City/State/ZIP: PO K '' ($ ' Z , . G - a. O e ' • • • 16.60
1
Phone: ( ) Fax: ( ) Garbage disposal 16.60
Hose bib <• APPLICANT•; ❑ CONTACT PERSON 16.60
Business name: i V ��k erl 3 16.60
Interceptor/grease
Contact name: 16,60
Address: �c� a g ��-
City /State/ZIP: PO C>g- 9 a b ' • 16,60
Phone: ( 3 ' 3 — a p
` \ O I Fax: ( 51)3) 3".6.t. - - 13 3 . ,
16) 16.60
E -mail: 0.f
8 V Cvl Q SOk ` r �`b tl t env-1 roll n'1 d c • ,
'CONTRACTOR
16.60
Business name: L• A I. ! + 6 ."42. 16.60 Water heater
' ' Other:
Subtotal 1.002 .54
Phone Minimum permit fee; $72.50 - v�o
Plan review (25% of permit fee)
Authorized signature; Wit, State surcharge ••t,' • of permit fee)
— /�����7.,-- _____ TOTAL PERMIT FEE g( ap
Print name: `z's\f" \ --0.-... Date; I _1 0 I a This permit application expires if a permit is not obtained within
180 days after It has been accepted as complete.
*Fee methodology set by Tri- County Building Industry Service Board.
i; 1 Bui ] ding\Permi]s1PLM- PermitApp.d,c 06/05 440 -1616T(]0 /02/COM/WEB)
From: Soil Solutions 503 331 7133 01/11/2012 11:43 11026 P.003/003
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Community Development
I', eimbursement District Payment Worksheet
1 H RI)
Planning /Engineering to complete: �„� �
Site Address: 9(,. 75 tSu / 4 "I r i `-'-
Parcel No.: oZ,S l t l$ fl p0 LI O
% 07G- /$
Reimbursement District No.: 0 -7 Amount Due: $ O 6 ? 3 . -� '
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Date: I-11- t By: C . � a s -v•A-2.-
Note: Amount due is as of date shown above.
Deferred Accounts:
Name: ,� 1
Phone Number: I
Legal:
Amount paid: $
Remaining to se paid; deferred amount: $
Building Division to complete:
Reimbursement amount paid: $ /61 O7( • /
•
Received by: ��,..,..., _ _
Return completed worksheet with copy of receipt to planning /engineering permit technician.
Planning /Engineering to complete:
Enter "paid" parcel tag.
Enter "deferral" parcel tag, if applicable.
Route copy of receipt and parcel information printout to Finance Department.
T:\ CURPLN \Masters\ReimburseWorksheet.doc 2/23/07
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,,,,:,,, , . a VT P.O. BOX 1260 DATE: 1 I 1 ' 1... 1
i ' '` 28128 SE HWY 212
' ! 1 a , .., �, <' EMPLOYEE: �
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� io BORING, OR. 97009 J
: �j i p o.,« PHONE: (503) 663 -2807 START /STOP TIME:
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,a R FAX: (503) 663 -9712
t v_ LIST OF MACHINERY & HOURS USED:
JOBS ®, 50/4 i C,i^ (5h irro i )54:1-5 - a3 N - a I / g
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'it ' WORK DONE:
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Portland Sand and Gravel Co.
10717 S.E. DIVISION ST. • PORTLAND, OREGON 97266
PHONE: 252-3497 • FAX: 254 -1668
TICKET
NUMBER 65608
DRIVER TRUCK NO. PURCHASE ORDER NO. DATE
•
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QUANTITY DESCRIPTION PRICE AMOUNT
GRAVEL
RIVER SAND
FILL SAND
CRUSHED ASPHALT
Lia CRUSHED ROCK X4-1. -
CRUSHED CONCRETE
TRUCK TIME
DUMP 7
RECEIVED BY v ' k (V�(t+C '
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TOTAL
'NOT RESPONSIBLE FOR DAMAGE CAUSED BY DELIVERING INSIDE CURB LINE
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