Permit Support Document Plumbing Permit AppIRKEIVED 9-1"2.0 - t3
Building Fixtures FOR OFFICE USE ONLY
S E P 0 12020 Rene;ved
- City of Tigard V.2."ze) 6V Permit Nr iS i 2CI(9j-DO tI{o�
ill i u 13125 SW Hall Blvd.,Tigard, Date/Rev
g ERI TIGARD Plan Review Other Permit No.:
Phone: 503.718.2439 Fa�g�}.{,N�tbIVISION DateBy: et p yljp Aetr,
TIGARD Inspection Line: 503.639.4175 Date Ready/By: q 1 Saris: ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method:q/ !/1,44 v liEg Supplemental Information
TYPE OF WORK igt-.f 4-r(, f ,• FEE* SCHEDULE ,.
X'New construction ❑Demolition For special information use checklist.
Description I Qty. I Ea. I Total
❑Addition:alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
INAD-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional ba ' hen 25.02
❑Master builder ❑Other: Fire sprinkler( .ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 6L✓5S 5� 1bQ-4). AA112. Catch basin or area drain 18.76
DryweAlb
b c Footing
1,leach line,or trench drain 18.76
City/State/ZIP: rr[_.fl
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: `,} Co Project name: Q.0 SK,__ Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
2 f /� 1 3 I ,"�, - 1 0 Rain drain connector 18.76
�Jt..J.� l Wn.t..t_� 'T lLJ Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
cy Dishwasher 25.02
� Q,n Q, s�`�S -- Z 1 Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: D A 1(� I 0 c,Q S3 Fixture/sewer cap 25.02
It /���1 J-��l Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: .I...210(�C(-\j - 0 lcs2' Water piping/DWV 56.29
Address: 10As `13 tStoc2„c 0.0[Limiok fa flauck 11,i/71 Other: 25.02
City/State/ZIP: -1- ud� '2-c 0 Subtotal
Phone:(1601, (.(oq 1'4$\ Fax:(G ) (o(o'i • 9SQ! Minimum permit fee: $72.50
CCB Lic.: IA 2 2 ZO Plumbing Lic.no.: �.(p•• g�(.t/iS review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: C� TOTAL PERMIT FEE 14,r $3
Print name: gy Date: 4� I i"2102 l This permit application expires if a permit is not obtained within 180 days
ln/l.� after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
IABuildieg\Permits\PLMU-PerrmtAppdoc 10/01/09 440-4616T(10/02/COM/WEB)