Permit p CITY OF TIGARD PLUMBING PERMIT
• COMMUNITY DEVELOPMENT Permit #: PLM2012 -00355
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/05/2012
Parcel: 25111 CD09800
Jurisdiction: Tigard
Site address: 9860 SW KIMBERLY DR
Project: Petrina Subdivision: KERWOOD ESTATES Lot: 28
Project Description: (2) lavatories, (2) tub, (2) shower and (2) water closets.
Contractor: EAST WEST PLUMBING INC Owner: PETRINA, JACK M &
10610 SE 145TH AVE 9860 SW KIMBERLY DR
HAPPY VALLEY, OR 97086 TIGARD, OR 97224
PHONE: 503 - 777 -1594 PHONE:
FAX:
FEES
Quantity Description Date Amount
2 ea Lavatories 12/05/2012 $50.04
Specifics: 2 ea Tub /Shower /Shower Pan 12/05/2012 $25.02
2 ea Water Closet 12/05/2012 $50.04
Type of Use: SF 1 12% State Surcharge - 12/05/2012 $15.01
Class of Work: ALT Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $140.11
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 ma obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: i Permittee Signature:
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 Applicatio CEIVED
Site Utilities ��,
City of Tigard DEC 0 5 Received Date/By: (�� /,^ Permit No.: (,,. 00 3�
a 131 2�I SW Hall Blvd., Tigard, OR 97223 �
1:1 Plan Review
Phone: 503.718.2439 Fax: 503.598.1 V 11 1 OF TIG RD Date/By: Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 tU� ~+ Date Ready/By: / See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: I Y Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
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
® I- 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:
Job site address: 9860 SW Kimberly Dr. Catch basin or area drain 18.76
City /State /ZIP: Tigard Oregon Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.: I Project name: Patrina Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
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: 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
Replace shower, replace tub,relpacetwo lays and two toilets Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
® PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Jack Patrina
Fixture /sewer cap 25.02
Floor drain /floor sink/hub 25.02
Address: 9860 SW Kimberly Dr.
Garbage disposal 25.02
City /State /ZIP: Tigard Oregon Hose bib 25.02
Phone: ( ) 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:
Roof drain (commercial) 12.51
Address: Sink/basir • 2, 25.02
City/State /ZIP: Solar units water) 62.54
u
Phone: ( ) Fax: : ( ) b how e shower pan . .- 12.51
E -mail: Urinal 25.02
Water closet 7,,,, 25.02
CONTRACTOR
Water heater 37.52
Business name: East West Plumbing Inc. Water piping/DWV 56.29
Address: 10610 SE 145 Ave Other: 25.02
City/State /ZIP: Happy Valley Oregon 97086 Subtotal
Phone: (971) 506 -5115 Fax: (503) 777 -1594 Minimum permit fee: $72.50
CCB Lic.: 102521 /0/ s''Tl I ,/ Plumbing Lic. no.: 26532 -pb Plan review (25% of permit fee)
7 State surcharge (12% of permit fee)
Authorized signature: TOTAL PERMIT FEE /40.1 I
Print name: Al Strey Date: 12 -5 -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.
I: \ Building \Permits\PLMU- PermitApp.doc 10/01/09 440.4616T(10/02/COM/WEB)