Permit CITY OF TIGARD PLUMBING PERMIT
3 COMMUNITY DEVELOPMENT Permit #: PLM2012 -00146
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 05/30/2012
Parcel: 2S110CB08400
Jurisdiction: Tigard
Site address: 12467 SW ST ANDREWS LN
Project: Mountain View Estates, Lot 9 Subdivision: MOUNTAIN VIEW ESTATES Lot: 9
Project Description: Residential backflow preventer for irrigation
Contractor: MALMEDAL ENTERPRISES INC Owner: JT ROTH CONSTRUCTION INC
PO BOX 207 PO BOX 1969
BANKS, OR 97106 LAKE OSWEGO, OR 97035
PHONE: 503 - 324 -0759 PHONE: 503-806-0602
FAX: 503 - 324 -0580
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 05/30/2012 $31.27
Specifics: 1 12% State Surcharge - 05/30/2012 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment - 05/30/2012 $41.23
Plumbing
Class of Work: OTR
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 No' nter. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or dir questions to O C b 'n 503.232.1987 or 1.800.332.2344.
155 ed By: • 9 Permittee Signature: / /
�� A- e //L
Call 503.639.4175 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.
Plumbing Permit Application
Building Fixtures FOR OFFICE USE ONLY
R
Ci of Tigard i Permit No.: LfloI A - D/
Date/ By: V • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
1111 I Other Permit No.: H , reel5�
Phone: 503.718.2439 Fax: 503.598.1960 DateBy: r Jl
TI GARD Inspection Line: 503.639.4175 Date Ready/By: Juris: 0 See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK FEE` SCHEDULE
For special information use checklist
Kt New construction ❑ Demolition
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 312.70
bit 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi - family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Q { Catch basin or area drain 18.76
Job site address:
`� 9- S ' .S v∎ Drywell, leach line, or trench drain 18.76
City / State/ZIP: ("1- DV-. 11 Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: Project name: \I k.Q Manufactured home utilities 50.03
Cross street/directions to job site \ J t 9 6 { / Manholes 18.76
`jC d• p v-s4,-,, h Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: Dv` `\ A � Lot no.: 1 Fixture or item:
Tax map /parcel no.: v `v Backflow preventer 'J 31.27
DESCRIPTION OF WORK • Backwater valve 12.51
/ � 3 I. Clothes washer 25.02
c S't J ( �' ut..e�C. � Dishwasher 25.02
!/( Drinking fountain 25.02
Ejectors /sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture /sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City /State/ZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT : . . - ❑ . CONTACT PERSON Interceptor /grease trap 25.02
Business name: '- Q ( Medical gas (value: $ ) Page 2
3 j �'h Primer 12.51
Contact name:
�C� S Q Roof drain (commercial) 12.51
Address: 1 1-e>1.9( Aft L�l.k it b .1,6t, Sink/basin/lavatory 25.02
City/State/ZIP:-F4) 6 od V R 7 7-9.> 3 Solar units (potable water) 62.54
Phone: (CV) ) 63 a �'1 -sf I Fax: (9 ), 6 a, y_ 6a..3 7 Tub /shower /shower pan 12.51
E -mail: f"M ��1, Q , , Urinal 25.02
J v..."-_, 1 or 4111)\01,01 Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: ( &n 4 r /I �� Water piping/DWV 56.29
Address: Q e o4 Other: 25.02
City/State/ZIP: lb t`)4 C3/ Subtotal
i1 Minimum permit fee: $72.50 73V
Phone: () 3 ��I �'� 9 Fax: (5 ) 3� D�2
CCB Lic.: Goa, t S` Plumbing Lic. no.: Plan review (25% of permit fee) 7
,,�,� State surcharge (12% of permit fee) g
Authorized signature: 1 � � / 0 (211���Q;Er� _ TOTAL PERMIT FEE g/ .O
Ong Date: S This permit application expires if a permit is not obtained within 180 days
Print name:
15 ! U g ,l 1 3 D/ h9. after it has been accepted as complete.
111 *Fee methodology set by Tri -County Building Industry Service Board.
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