Permit CITY OF TIGARD PLUMBING PERMIT
III ■ COMMUNITY DEVELOPMENT Permit#: PLM2016-00226
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/26/2016
Tri;, It D9 Parcel: 2S1060001500
Jurisdiction: TIGARD
Site address: 17191 SW HOLLY RIDGE LN
Project: River Terrace Northwest,Lot 18 Subdivision: RIVER TERRACE NORTHWEST Lot: 18
Project Description: Installation of residential backflow preventer for irrigation.
Contractor: CASCADIAN LANDSCAPERS, INC. Owner: POLYGON WLH, LLC
21510 NW FARM PARK DR 109 E 13TH STREET
HILLSBORO, OR 97124 VANCOUVER,WA 98660
PHONE: 360-695-7700
PHONE: 503-647-9933
FAX: 503-647-9922
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 04/26/2016 $31.27
Specifics: 1 12%State Surcharge- 04/26/2016 $8.70
Plumbing
41 ea Minimum Fee Adjustment- 04/26/2016 $41.23
Type of Use: SF Plumbing
Class of Work: OTR
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.
Issuedy: r Permittee Signat -
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
App 26 ?r,16Site Utilities 1.012 01.1.1( I.: I Sl'. 011.1
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City of Tigard Receivedtc Do (-_p, PermitNo.: Rtypoi 4--gyp- pi.e,
• 13125 SW Hall Blvd.,Tigard,Op 1977,23 + t 1() '; Plan Revie
Phone: 503.718.2439 Fax: 503.598'1 b0 Date/By: Other Permit No.: My(do/ QD/g f
Inspection Line: 503.639.4175 Date Ready/By: _furls: ® See Page2
I I c :1 RI) Internet: www.ti d-or. ov y y' nt l for
gar S Notifed/Method: Supplemental Information
e ""WP:
"W TYPE OF WORK ( FEE* SCHEDULE '-'4,4 -741:4-.:''"--`.
®New construction 0 Demolition For special information use checklist.
Description Qty. I Ea. Total
0 Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
S SFR(1)bath 312.70
CATEGORY OF CONSTRUCTION
® 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
buildingSFR(3)bath 500.32
0 Accessory 0 Multi-family
Each additional bath/kitchen 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
11141 JOB SITE INFORMATION'AND LOCATION .. Site utilities:
Job site address:.17192 SW Holly Ridge Lane 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.: 1 Project name:Riverside Terrace Manufactured home utilities 50.03
Cross street/directions to job site:Roy Rodgers and Scholls Fer 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: 1 Lot no.:18 Fixture or item:
Tax map/parcel no.: Backflow preventer 1 31.27 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Backflow Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
® PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name:Polygon Northwest Company Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:109 E.13th Street
Garbage disposal 25.02
City/State/ZIP:Vancouver,WA 98660 Hose bib 25.02
Phone:(360)695-7700 Fax:( ) Ice maker 12.51
® APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name:Cascadian Landscapers,Inc. Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Art Meisner
Roof drain(commercial) 12.51
Address:21510 NW Farm Park Drive Sink/basin/lavatory 25.02
City/State/ZIP:Hillsboro,OR 97124 Solar units(potable water) 62.54
Phone:(503)647-9933 Fax::(503)647-9922 Tub/shower/shower pan 12.51
E-mail:art@cascadianlandscapers.com Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name:Cascadian Landscapers,Inc. Water piping/DWV 56.29
Address:21510 NW Farm Park Drive Other: 25.02
City/State/ZIP:Hillsboro,OR 97124Subtotal
Phone:(503)647-9933 Fax:(503)647-9922 Minimum permit fee: $72.50 72.50
Plan review (25%of permit fee)
CCB Lic.:5 -- t"-Crj B S Plumbing Lic.no.:LCB#5185
7 State surcharge(12%of permit fee) 8.70
Authorized signature: ' TOTAL PERMIT FEE 81.20
Print name:Bryan Rose Date:4/25/2016 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\Pemits\PLMU-PemitApp.doc 10/01/09 440-4616T(l0/02/COM/WEB)
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
17191 SW HOLLY RIDGE LN, SHERWOOD,
OR, 97140
Record Type: Record ID:
Residential - Plumbing PLM2016-00226
Inspection Type: Inspector:
399 Plumbing final Allyson Armstrong
Result:
PASS - NoCofO
Comments:
Collected back flow report.
Violation Summary:
Inspector Contractor