Permit (60) p
CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2016-00042
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/02/2016
Parcel: 2 11 BA1160
S 0 0
Jurisdiction: TIGARD
Site address: 14236 SW 118TH CT
Project: Medallion Meadows, Lot 9 Subdivision: MEDALLION MEADOWS Lot: 9
Project Description: Irrigation for backflow.
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: 503-639-2639
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. .
Issued By: v, Permittee ig ture:
Call 503.639.4175 by 7:00 a.m.for the next available inspection dat
This permit card shall be kept in a conspicuous place on the job site until comple ion 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
City of Tigard ) Received
b r tPermit No.:
13125 SW Hall Blvd.,Tigard,01�,- Ty?3� Date Plan Review
Phone: 503.718.2439 Fax: SU3�t+ 4-960 I v l t, Date'By: Other Pennit No.:
Inspection Line: 503.639.4175 i �, :>vL
y�j �. Date Ready By: s: ITISTQN
® See Page 2 for
Internet: www.ti�ard-or.gov v i"• `
_ _ ��,-r,�ti.- i-� Notified Method: Supplemental Information
TYPE OF WORK ''; FEE* SCHEDULE
New construction oFor special information use checklist.� n
Description I Qty. I Ea. Total
❑ Addition/alteration/replacement ❑'ether: New 1-2-famih dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
I-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑ Accessory building ❑ Multi-family SFR(3)bath 500.32
Each additional bativ'kitchen 35.02
❑ Master builder ❑Other: Fire sprinkler(_sq.ft.) Page 2
JOB SITE INFORINL&TION AND LOCATION Site utilities:
Job site address: I �/ Catch basin or area drain 18.76
Drywell,leach line.or trench drain 18.76
Ciry/State/ZIP:
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name:
Manufactured home utilities 50.03
Cross street'directions to job site: Manholes 18.76
6:�11IL26
di'/1 `r"� fr (y Rain drain connector 18.76
v
Sanitary sewer(no.linear ft.: J Pa_e 2
Storm sewer(no.linear tt.:-) Page 2
Water service(no.linear ft.:_) Pa,-,e_'
Subdivision: 11� �LG1)Al /t70t7Jw/% Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27 3,1,,X7
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 21.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
PROPERTY OWNER ❑ TENANT Expansion tank 12.51
, Fixture/sewer cap 25.02
Name: 3,r r'N (q�;N,;( ,T i✓
Address: n,
Floor drain/floor sink,hub 25.02
�,�" �^ S� �
Garbage disposal 25.02
City/State/ZIP: 7 OP-
Hose bib 25.02
Phone:fj D} Fax:( ) Ice maker 12.51
APPLICANT ❑' CONTACT PERSON Interceptor/grease trap 25.02
Business name: I'� r>-� ^/ Medical gas(value:S ) Page 2
Contact name: Jkii�
J: T ��✓
f; Pt-inter 12.51
�5E
Roofdrain(commercial) 12.51
Address: / LC n7
iv .i � v Sink,basin;lavatory 25.02
City/State/ZIP: . ren vim. Solar units(potable water) 62.54
Phone: Jp ) ��-`✓ ' Fax: :( ) Tub,shower'shower pan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: •� f� VPL A IA-t- Water piping,DW V 56.29
Address: 62 Other: 25.02
City/State/ZIP: /'�G 3J/t �% Subtotal -3/. )-7
Phone:(�j ) ��� %`/ Fax:( ) Minimtun permit fee: 572.50
Plan review (25°6 ofpennit fee)
C�Lic.: � Plumbing Lie.no.: �7C
State surcharge(121.ofpennit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: Date: 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 term it;PIAR PermitApp.d'C 10 01(19 C ) 440-46161110 02 CONI\\'GBI