Permit IN ° Community Development
T I G n ii Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
V 0 1 0 Mailing Address:
G / /' / ,/I Ci /Sta /Zip:
� Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
�/ CANCEL PERMIT APPLICATION.
./ ❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). •
/ n z
Permit #: 2-00 0Q) 0
Site Address or Parcel #: 75 90 > l/ Aires -76j Cj 1 4 / , 4 i
Ip
Project Name: t- V 6
Subdivision Name: Lot #:
EXPLANATION: u/ A J C-1- _ S FR_ i / i C /j/J C
UN P f'L17 0007-- —06 Y z_,
• V /?
Signature: /� , v Date: � - id - 0 P
Print Na e , f MA/ ,Q (:-/f (., 6 C, V—
Refund olr lice
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an apR�{llkation is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued pehriits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date 4 , /(.- B
Refund Processed: Date it j/i"J By Invoice Processed: Date By
Permit Canceled: Date .46;67 /0p By .. , , Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPerrnitAction.doc Rev 07/26/07
ti '
Community Development
T i c li o Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ►� City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
1'175 Mailing Address:
6 r Ci /St /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
v/ CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
p INVOICE FOR FEES DUE (attach case fee schedule and explain below).
El REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). .
Permit #: Pi,, i zoo-F- ^ 00V 0
Site Address or Parcel #: 754' J W // /1 3 W g /
t - Project Name: v 8 ¶ ,
•
Subdivision Name: Lot #:
EXPLANATION: In/A P SEJ? V l C //VS'744Z-['
11 N P e fin zoo - —06 (. -7z.
Signature: Date: b l,(
Print Na : ,/ . 5A 1,9 AI 6 1_4 L 0 C r__
2c n l'
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an ap ation is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued pchnits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fce for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date 4 i /Oa By ('
Refund Processed: Date A/ //9— By .0‘ Invoice Processed: Date By
Permit Canceled: Date .46/f7 /pe By - - -•, Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \Regl'ermitAction.doc Rev 07/26/07
1
�_ 0
z.. // li CITY OF TIGARD PLUMBING PERMIT
e COMMUNITY DEVELOPMENT PERMIT #: PLM2007 -00503
TIGARD DATE ISSUED: 11/13/2007
13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S101A6 - 01607
SITE ADDRESS: 07540 SW HERMOSO WAY ZONING: MUE
SUBDIVISION: HERMOSO PARK LOT: 009 JURISDICTION: TIG
PROJECT: RAND
Project Description: Install 40' of water service.
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: 40 ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
RAND, STEPHEN C
7540 SW HERMOSO WAY Description Date Amount
TIGARD, OR 97223 [TAX] 8% State Surcharl 11/13/2007 $5.80
[PLUMB] Permit Fee 11/13/2007 $72.50
Phone : 503- 888 -5539 Total $78.30 •
Contractor:
BURFITT PLUMBING
PORTLAND, RL
OR 9 7 21 3 REQUIRED ITEMS AND REPORTS
OR 921
Contact # : PRI 503- 287 -1267
FAX 503 -331 -3933
•
Reg #: LIC 1076
PLM 26 -IIPB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws.
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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center.
Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 -0001 -0100. You may obtain copies of these rules or direct questions to OUNC
by calling 50 . • •. • • 1.800. 2.2344.
Issu d By: / ,/ ! Permittee Signa� c if . / v `--Z
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.
11/09/2007 13:20 FAX 503 3313933 BLTRF I TT PLUMB INC. 1
di. •-■ . :
_. .x?-' 1-•'' i • ,/i'
Plumbing Permit ApplitatiOn. \---1 ---,--- U ' "---. ---' FOR (11 1 1( 1. 1 :,1; ()NI 1
City of Tigard Received
Datell3y: ///16 7 - ' =IL" 407-415
Ii
• 13125 SW Hall Blvd., Tigard, OR 972/1011 0 9 2007
Plan ncview Other Permit No.!
- Ine
" Phone: 503.639.4171 Fax,A9,4%.1966 II u A : s) ik Date
spction Line: 503.639.4 1t 11 X -‘ ' \ ' Ready/By: .:/011 121 See Page 2 kr
Internet -k-r. 7111. ' ; !OM • • S. iallad " ' : ' • //e, Supplemental Information
TYPE s : ,' '. . l iti
0 New construction 0 Demolition For special information we checklist
- Description 1 qz I En. I T. 0121
MI Addition/alteration/replacement 0 Other New 1- 2-family dwellings (includes 100 ft_ for each utility connection)
0*T*Cr010::.:Ot):.c SFR (I) bath 249.20
1- and 2-family dwelling 0 Commercial/Industrial SFR (2) bath 350.00
0 Accessory building 0 Multi-family SFR (3) bath 399.00
Each additional bath/kitchen 45.00
0 Master builder 0 Other
Fite sprinkler L.... L.... sq. ft.) Page 2
4
f* S#...: i:s . .
'.`.;::-:".'::::''.. :::... ...-: ,.:•:„.;=::;' site wellies
Job site address: is Ltb 51,3 1-11,4- vytoc) toc,..4_)„,,,. Catch basin or ansa drain 16.60
City/Stoic/VIP: '17 o 0) 0 k q • 7 73' L) Drywall, leach line, or trench drain 16.60
i
Suiteibldgiapt. no.: Project name: .e--e,-r, Footing drain (no. !incur ft: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
51k) 7214 c) , kh-e Rain drain connector 16.60
-
Sanitary sewer (no. linear ft.: ____,) Page 2
Storm sewer (no. linear ft.: i Page 2
....
Subdivision: - T Lot no.: Water service (no. linear ft.: lip) I Page2 65.a
Fixture or item
Tax map/parcel no.:
, ., Abscaption valve 16.60
:„:„.... .:.'.'::;,'.:.•'• i' :...... :.>; :,....:„ '' : ' : .1:.1 .. 7 : , • Page 2
N e4A....) lit) 1 S Backwater valve 16.60
a L 1 Ce---: 4D Clothes washer 16.60
Dishwasher 16.60
: 1 : :'•a: : :' : %':':. : ;, ,' .',. ',. ROPEktii:::14**;,::j,::;:.::.'‘;',,:2,:,.(r"-::::•:::':':'.':!::::,,,:.:',.:::::::.F. ..:-itI;:iti, .,•:.::
Drinking lb Ejectors/sump
_ 16.60
16.60
Name: 0 HA P-4 KY7
_ Expansion tank 16.60
Address: Fixturt,/scwer cap 16.60
City/State/ZIP: Floor drain/floor sinkihab 16.60
Phone: (573 ) n6 - .5- 57 Fax: ( ) Garbage disposal 16.60
1:1: .:.•... z.:: t:512;;OtIN*Aet.:ABSPN::''::'?:':" Hose bib 16.60 Iccmakcr 16.60
Business name: BL,I.c; + +- pt,,,b.,,. Interceptor/grease trap 16.60
Contact name AAA k er Ta. 1 or g_c)•. Ill 40,,N Medical gas (value: $ ) Page 2
Address: 7 - 7 -- 6 t\l 140- bSr-L-C) SIJ Primer 16.60
City/StateJZIP: i.) .1-1 " (..) 1 6 tc?.... 972! '-). Roof drain (commercial) 16.60
1 2 C 7 Fax: : ( 3.6i _ sci .-- SW1E/basin/lavatory 16.60
Rib/shower/shower pan 16.60
E-mail:
Urinal 16.60
' '' p. n r 1 91 1 :::: ''' :•'•:. -, - - . ..:::: . . , :f:: 7 '; ,•,- :: ::::i. P ::',..: Water closet 16.60 .
Business name: 12 ,--1-i- riwyl b i ylCj•-..,_ Water heater 16.60
Address: (e) ,:',.. k) r -117 IdiP t Other
City/State/ZIP: ,p,„..1",„ p q 72_ 1 I Subtotal -
) Minimum permit fee: $7150 _,,,
Phone: ( 666) 2%7 - 1 2.4 -7 Fac ( 603 3 3 1 - 3(13 Residential baddlow minimum permit fee: $3615 ( C.
- )
Co; Lie.: . 1014; Plumbing Lie. no.: 26 - I/ Plan review (25% of permit fee)
Authorized signalise: / /
, 1 State surcharge (8% of permit ftc) 5.80
2 I i -
"..:a1111- TOTAL PERMIT FEE j g , 5 e)
Print name: 144er - 1;% .1 Date: ii igi 0-7 This permit application expire" if s permit boot obtained within
180 days after it has been accepted as complete.
*Fee methodology set by Tri-C-otmty Building Industry Service Board.
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