Permit Support Document Plumbing Permit Appl}C ' CEIVED Q-I-20-6
Building Fixtures SEP ii 1 2020 FOR OFFICE USE ONLY
Received Permit No.City S Hall
^^''Ty nf TIGARD Date/By: ��2/ �a 115T2�I w �QO yb7
■ 13125 SW Hall Blvd.,Tigaz�d3 H1C 972� Plan Review
- Phone: 503.718.2439 Fa UiL I�c(DIUISION Date/By: 9-/'i.30 4C.6, Other Permit No.:
Inspection Line: 503.639.4175 Date Read B .iuris: ® See Pa et
2 for
TIGARD Y Y: p 7� g
Internet: www.tigard-or.gov Notified Method/ '7/� ' °a `ier Supplemental information
TYPE OF WORK v.'ar/.-(i -_7NZ- FEE* SCHEDULE
KNew construction 0 Demolition For special information use checklist
-- - - Description I Qty. 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
K1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building 0 Multi-family
Each additional batlVd/itchcn 25.02
❑Master builder 0 Other: Fire sprinkler( Sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: t14,55 1 1 b�•1 �'d'2 Catch basin or area drain 18.76
DrmG ��� Footing
drain
o. l or trench drain 18.76
2
City/State/ZIP: ,` '�
-•� n ^ �/ p ,' Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: i s Project name: ) /s�l� .... Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
R.t /� (' ( ,y -4S Rain drain connector 18.76
�.-l� 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
Si? Q Dishwasher 25.02
C k.I� mi/�(` oS V • Drinking fountain 25.02
\\\ c'\ Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: 1-- Q,^1,�� �� Fixture/sewer cap 25.02
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 0 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: Oeu_elo p mom_ N(/. G Wo1co,a' - Waterpiping/DWV 56.29
Address: (Q W kta Co1.u(rblia Q.(v2Q i4 ( Other: 25.02
..{1
City/State/ZIP: \ could. 49-0(00 Subtotal
Phone:(%"C1, (c (off 1--Ttl Fax:(,Sb3 co(o-i gglq.1 Minimum permit fee: $72.50
CCB Lie.: kke aa� umbing Lie.no.: An. P�-4 Pa Plan review (25%of permit fee)
1� State surcharge(12%of permit fee)
Authorized signature:` Alt^ TOTAL PERMIT FEE /24•53
Print name: 2 Date: 4( t f Xf ) This permit application expires if a permit is not obtained within DSO days
"""III"--- after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building'.Pemdts\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)