Permit (60) n CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2016-00043
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/02/2016
Parcel: 2S110BA12500
Jurisdiction: TIGARD
Site address: 14121 SW 118TH CT
Project: Medallion Meadows,Lot 18 Subdivision: MEDALLION MEADOWS Lot: 18
Project Description: Backflow for irrigation.
Contractor: SUMMIT LANDSCAPE LLC Owner: JT ROTH CONSTRUCTION INC
PO BOX 3610 FOUR D CONSTRUCTION CO
HILLSBORO, OR 97123 12600 SW 72ND AVE#200
TIGARD, OR 97223
PHONE: 503-380-7618 PHONE:
FAX:
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 02/02/2016 $31.27
Specifics: 1 12%State Surcharge- 02/02/2016 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment- 02/02/2016 $41.23
Class of Work: OTR Plumbing
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 1.800.332.2344.
Issued By: Signature:
C r
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 completi 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
' ' Received
City of Tigard a / /ry Permit No.:
13125 SW Hall Blvd.,Tigard,0[>R 9 '3� 1� f Date By: t0
9 nn��n Plan Review
Phone: 503.718 2439 Fax: 5(f3 1 t; 66 �VDate:By: Other Permit No.: 1
Inspection Line: 503.639.4175 Date Ready'By: Jnris: 0See Page 2 for
Internet: www.tigard-or.gov �� °i!,^',t ';.d 3" Notified.Method: Supplemental Information
TYPE OF WORK !s' FEE*.SCHEDULE
ti
New construction ❑j �h��j{6sn For special information use checklist
.' Description p Qty. I Ea. Total
❑ Addition/alteration/replacement ❑other. New l-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building ❑ Multi-family SFR(3)bath 500.33
Each additional bath/kitchen 25.02
F-1Masterbuilder El Other:
Fire sprinkler( sy.ft.) Page 2
JOB SITE INFORNLATION AND LOCATION Site utilities:
Job site address: Catch basin or area drain 18.76
Drvwell,leach line,or trench drain 18.76
City/State/ZIP: �`t✓t In v
Footing drain(no.linear ft.: I Page 2
Suite/bldg./apt.no.: Project name: Manufactured]ionic utilities 50.03
Cross street/di rect ions to job site: Manholes 18.76
/ to
L Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Stone sewer(no.linear ft.: ) Pace 2
� Water service(no.linear ft.: 1 Page 2
Subdivision: �� LLQ, 1'� �t�Jw�/ Lot no.: Fixture or item:
Tax map/parcel no.: Backilow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors%sump 35.02
PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: 7 3j7',V �ovlv,( r i; Fixture/sewer cap 25.02
5'1'/ n-7 Floor drain;floor sinkltub 35.02
Address: 1406
Garbage disposal 25.02
City/State/ZIP: 71,14;1V 0;4 Hose bib 25.02
Phone:Fq) ) Fax:( ) Ice maker 12.51
APPLICANT 1 ❑ CONTACT PERSON Interceptor'grease trap 25.02
Medical gas(value:S 1 Pace 2
Business name: TT r'. rN &1v
Contact name: Primer 12.51
Roof drain(commercial) 13.51
Address: /�Z�n-� n7
�v -� / v Sink/basin lavatory 25.02
City/State/ZIP: -�i_Z L� vim. Solar units(potable water) 62.54
Phone:raj Fax: :( ) Tube showershowerpan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Water piping DWV 56.29
Address: �� ,, Other: 25.02
City/State/ZIP: /�G jJtt 5in Subtotal
5/,l
Phone:(C Fax:( ) Minimum permit fee: $72.50
C�Lie.: Plumbing Lie.no.:
Plan review (25°a of�pennit fee)
Slate surcharge(l'_%of pennit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Date: This permit application expires if a permit is not obtained xs-ithin 180 days
after it has been accepted as complete.
```��/ *Fee methodology set by Tri-Cmmty Building Industry Service Board.
1:Building Permits ITAIC-PermitApp.doc 10 01 09 C y 440-46167(Ill02 CONI wG61
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