Permit CITY OF TIGARD PLUMBING PERMIT
II I : COMMUNITY DEVELOPMENT Permit #: PLM2012 -00267
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 09/13/2012
Parcel: 2S111CB01712
Jurisdiction: Tigard
Site address: 10155 SW HOODVIEW DR
Project: Carver Subdivision: HOOD VIEW Lot: 11
Project Description: Connect existing house to sewer service. Reversing plumbing under house.
Contractor: RAYBORN'S PLUMBING INC Owner: CARVER, WILLIAM A SUSAN M
19990 SW CIPOLE RD 10155 SW HOODVIEW DRIVE
TUALATIN, OR 97062 TIGARD, OR 97223
PHONE: 503 - 639 -8507
HONE: 503 - 692 -4139
FAX: 503 - 691 -2328
FEES
Quantity Description Date Amount
100 If Sewer Service 09/13/2012 $62.54
Specifics: 1 12% State Surcharge - 09/13/2012 $10.51
Plumbing
Type of Use: SF 25 Misc Other Fee 09/13/2012 $25.02
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $98.07
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 fication 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 ' ect questions to OU C b g 50 .232.1987 or 1.800.332.2344.
Is ued By: Permittee Signatur : (
4 1"_
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
Site Utilities RECEIVED
City of Tigard Received 1 A Permit No.: t / / 49.--00,20 7
• 13125 SW Hall Blvd., Tigard, OR 97221 Day:
I P 1 3 Z O 1 Z Plan Review Other Permit No.:
Inspection Pho ne: 503.718.2439 Fax: 503.598.1 60
on Line: 503.639.4175 Date/By.
T I G n R D '' CITY OF TIGARD Date Ready/By: lulu: El See Page 2 for
Internet: www.tigard - or.gov - a NotiSed/Method: Supplemental Information
TYPE OF ' • p , p FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑ Addition/alteration/replacement ® Other. Sewer New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 312.70
® 1- and 2- family dwelling ❑ Commercialindustrial 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 L_ sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 10155 SW Hoodview Dr. Catch basin or area drain 18.76
City/ State/ZIP: Tigard, OR 97224 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: Sattler & 100th Manholes 18.76
Turn left on 100 right on Kable - 2 house on right. Rain drain connector 18.76
Sanitary sewer (no. linear IL: 10(1) Page 2 62.54
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Installation of sewer line
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: William and Susan Carver Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 10155 SW Hoodvvew Dr.
Garbage disposal 25.02
City/ State/ZIP: Tigard, OR 97224 Hose bib 25.02
Phone: (503)639 -8507 Fax: ( ) Ice maker 12.51
® APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02
Business name:
Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: See Property Owner Above
Roof drain (commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/ State/ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Rayborn Plumbing Water piping/DWV 56.29
Address: 19990 SW Cipole Rd. Other: ReversePlumbing 25.02 25.02
City/State/ZIP: Tualatin, OR 97062 Subtotal 87.56
Phone: (503) 692-4139 Fax: ( ' i 69y-a 702f) Minimum permit fee: $72.50
CCB Lic.: 87852 i / I) Plumbing 4 ( . no.: 34 -166PB Plan review (25% of permit fee)
� , State surcharge (12% of permit fee) 10.51
Authorized signature: i i f TOTAL PERMIT FEE 98.07
Print name: Kenneth Provancher Date 8 - 28 - 12 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.
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ALOHA SANITARY SERVICE y INVOICE NO.
8600 SW Hillsboro Hwy., Hillsboro, OR 97123 1 7 -i 7 :
503 -644 -2797 • 503- 648 -6254 • 503 - 846 -1951 (FAX)
www.alohasanitary.com * Email: info @alohasanitary.com
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PAID BY CHARGE ❑ CHEC CASH ❑ CREDIT CARD ❑
DATE /6) -- 'r,' - -di' Z DRIVER , ', - r.,�� ' l/c4K4 oa! AMOUNT
PUMP SEPTIC TANK
❑ INSPECTION FEE 1
❑ SERVICE CALL 1
❑ LABOR, LOCATING, DIGGING, BACKFILL i
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THIS /s NorA SEPTIC SYSTEM /NS TION REPORT - - I TOTAL $ , `,
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I . 14 1 TYPE OF TANK: STEEL ❑ / ONCRETE ❑ PLAS ❑ HOMEMADE ❑
HORIZONTAL ❑ /VERTICAL ❑ RECTANGLE ❑ ❑ OTHER
SIZE OF TANK: 350 ❑ 500 ❑ 750 ❑ 1000 ❑ 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑
LID LOCATION: INLET ❑ OUTLE ❑ / MIDDLE ❑ ENTIRE TOP ❑
TANK CONDITION: GOOD ❑ FAIR ❑ d POOR ❑
FITTINGS: BAFFLES ❑ CONCR E ❑ CAST IRON ❑ PLASTIC ❑
GROUND COVER OVER TANK 7 / 6 sk
COMMENTS f j 1 7
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Customer Signature DATE r`6-� arr`