Permit (133) t CITY OF TIGARD PLUMBING PERMIT
;11 11 COMMUNITY DEVELOPMENT Permit#: PLM2019-00368
TARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/16/2019
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Parcel: 2S1070000102
Jurisdiction: Tigard
Site address: 16824 SW ROCKHAMPTON LN
Project: Polygon at Roshak Ridge,Lot 234 Subdivision: ROSHAK RIDGE Lot: 234
Project Description: Adding(1)backflow preventer for landscape irrigation.
Contractor: CASCADIAN LANDSCAPERS, INC. Owner: POLYGON WLH LLC
36700 SW BLOOMING FERN HILL RD 703 BROADWAY ST STE 510
CORNELIUS, OR 97113 VANCOUVER,WA 98660
PHONE: 503-647-9933
PHONE: 360-695-7700
FAX: 503-647-9922
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 09/16/2019 $31.27
Specifics: 1 12%State Surcharge- 09/16/2019 $8.70
Plumbing
41 ea Minimum Fee Adjustment- 09/16/2019 $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.
Issued By: \____.4..A.....„
Permittee Signature: � k---\ AM��
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
Building Fixtures '..-`,--a 1 �� FOR OFFICE USE ONLv
City of Tigard Received (� i 1,. i C ^�,,.
-►)�#1 In 13125 SW Hall Blvd.,Tigard,OR 97223 `;1 j 10;h Date/By:
ltU�1 iLi J� Permit No � WAS
Ys.
Review
Phone: 503.718.2439 Fax: 503.598.1960 Other Permit No.:M `� �^
Date/By: \"�T r l Fey,
Inspection Line: 503.639 4175
T 1 G A R D ; Date Read /B Mris: 64 See Page 2 for
Internet: www.tigard-or.gov , Ready/By: Q,
�; NNotified/Method: ��,t \c-i. Supplemental Information
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For special information use checklist
®New construction ❑Demolition
Description I Qty. I Ea. ] Total
0 Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
`'i 441' 4,;CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
® 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
# JOB SITE INFORMATION AND LOCATION ' " Site utilities:
Job site address:16824 SW Rock Hampton Lane Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Beaverton,OR 97007
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: 1 Project name:Roshak Ridge 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
Water service(no.linear ft.:_) Page 2
Subdivision: 1 Lot no.:a3t 1, Fixture or item:
Tax map/parcel no.: �T Backflow preventer 1 31.27 31.27
art ' ,- ..• Backwater valve 12.51
DESCRIPTION'OF.WORK:. �, 4,,,
Clothes washer 25.02
Irrigation Backflow
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
x�-
x t
raPROPERTY'QWNER ter. 0 TENANT`° Expansion tank 12.51
Name:Polygon Northwest Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:703 Broadway St,Suite 510
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:36700 Sw Blooming Fern Hill Rd Sink/basin/lavatory 25.02
City/State/ZIP:Cornelius,OR 97113 Solar units(potable water) 62.54
` rnone:(503)6479933 Fax::( ) Tub/shower/shower pan 12.51
E-mail:Kari@cascadianlandscapers.com Urinal 25.02
Water closet 25.02
. CONTRACTOR, „
Water heater 37.52
Business name:Cascadian Landscapers,Inc WaterPm iP g/DWV 56.29
Address:36700 SW Blooming Fern Hill Rd Other: 25.02
ti
City/State/ZIP:Cornelius,OR 97113 Subtotal
Phone: 503 647-9933 -N. Fax:Fax: Minimum permit fee: $72.50 72.50
Plan review (25%of permit fee)
CCB Lic.:51443 / Plumbing Lic.no.: "CsV3
State surcharge(12%of permit fee) 8.70
Authorized signature• �. ""�, "1-‘.?A -)C.).
rTOTAL PERMIT FEE gi:20
Print name:Art Meisner Date:9/13/19 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\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)