Permit (201) CITY OF TIGARD PLUMBING PERMIT
1111....-
COMMUNITY DEVELOPMENT
Permit#: PLM2016-00591
T(C(GARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/05/2016
Parcel: 2S112AD00500
Jurisdiction: Tigard
Site address: 14650 SW 72ND AVE
Project: Rogers Machinery Subdivision: None
Project Description: Install new 2"DCOA underground backflow device for irrigation cross connection prevention. Lot: None
Contractor: RAYBORN'S PLUMBING INC Owner: UNION CENTRAL LIFE
PO BOX 69 TREASURY SERVICES
19990 SW CIPOLE RD ATTN: DIANE THOMAS
TUALATIN, OR 97062 PO BOX 888
CINCINNATI, OH 45240
PHONE: 503-692-4139 PHONE:
FAX: 503-691-2328
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 12/05/2016 $31.27
Specifics: 1 12%State Surcharge- 12/05/2016 $8°70
Plumbing
Type of Use: COM 41 ea Minimum Fee Adjustment- 12/05/2016 $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 .. ..'n a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
‹f:) ,-41-- -J-e______.
i
Call 503.639.4175 by 7:00 a.m.for the next available in-7c 'on ,ate.
This permit card shall be kept in a conspicuous place on the job site til o" pletion of the project.
Approved plans are required on the job site at the time of ea inspection.
Plumbing Permit Application' ..,
Site Utilities !i;_12, 0 ;5
z �O16 rolz orrlct. t sl: O\I.l
City of Tigard Received
IN 4 13125 SW Hall Blvd.,Tigard OR 9 �3rDate/By:4��5�% Permit No/6 �4, -.005
I Phone: 503.639.4171 Fax 503.59841 60= Plan Review
Inspection Line: 503.639.4175 (`I, '``' J. ,% i°. DateBy: Other Permit No.:
T IC, \1.f) to Date Ready/By: Jur s: ®See Page 2 for
Internet: www.tigard-or.gov
Notified/Method: I Supplemental Information
TYPE OF WORK ., .:,
FEE* SCHEDULI4'1 -- h,',',. :.:
0 New construction ❑Demolition For special information use checklist
®Addition/alteration/replacementDescription Qty. j Ea. Total
0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
® 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
0 Accessory building 0 Multi-family SFR(3)bath 500.32
❑Master builder Each additional bath/kitchen 25.02
❑Other:
Fire sprinkler( sq.ft.) Page 2
Ala''' ;, l., X9111 L
_.`, .?;-'",.,, £1..t� r. I�Q�4f„z., ..,4js.,.,._ '. Site utilities:
Job site address: IL((1,5-0. st„t, 7 Z'd A%,1". Catch basin or area drain 18 76
City/State/ZIP: 714A-1L0 / 02 et-722k( Drywell,leach line,or trench drain 18.76
Suite/bldg./apt.no.: I Project name: Footing drain(no.linear ft.:_) Page 2
12J5�ri ��6k e.r 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
Subdivision: Water service(no.linear ft.:_) Page 2
I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer
X 31.27 (��
DESCRIPTION OF WORK Backwater valve 12.51
I/JStAI.L �av 7,, � LQ� Clothes washer 25.02
a t S rvJvt i Dishwasher 25.02
'�'r r r'S y 4,'a^ c f.‘") f a nn G c-ti-.0 Drinking fountain
25.02
e ttJ s.,..4-i ^ Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Address: Floor drain/floor sink/hub 25.02
City/State/ZIP: Garbage disposal 25.02
Hose bib 25.02
Phone:( )
I Fax:( ) Ice maker
12.51
0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Contact name: Primer 12.51
Address: Roof drain(commercial) 12.51
City/State/ZIP:
Sink/basin/lavatory 25.02
Solar units(potable water) 62.54
Phone:( ) I Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal
25.02
CONTRACTOR Water closet 25.02
Business name:RAYBORN'S PLUMBING INC Water heater 37.52
Address:P.O.Box 69 Waterpiping/DWV 56.29
Other. 25.02
City/State/ZIP:Tualatin,OR 97062
Subtotal 31 1,7
i Phone:(503)692-4139 Fax:(503)691-2328 Minimumermit fee: $72.50
p ')2i
CCB Lic.:87852 Plumbing Lic.no.:34-166PB Plan review (25%of permit fee)
Authorized signature: State surcharge(12%of permit fee) 32.
TOTAL PERMIT FEE elite
Print name: ,44,43 4 er 0 r...„, I Date:1215/?0 1
(' I 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.