Permit Support Document Plumbing Permit ArmBlinnCEIVED q-l-2o_g
Building Fixtures C FOR OFFICE USE ONLY q (foil City of Tigard S E P 01 2020 Received V2170 n ` Permit No.�tS�/ '.-DO
Ili - . 13125 SW Hall Blvd.,Tigard,OR 97223 DateBBy: / /��j` r I
Phone: 503.718.2439 Fax: 5030 weFTIGARD Plan Review
Date/By: 94i w ,AGO Other Permit No.:
Inspection Line:
503.639.4175 BUILDING DIVISIONTIGARD Date Ready/By: / // zInternet: www.tigard-or.gov Notified/Method: T// KO t1d4. ®pSpelee mPea neta zl lfoorf ormation
TYPE OF WORK -2,9- L. 77 Arv-4 FEE* SCHEDULE
[ New construction ❑Demolition For special information use checklist
Description I Qty. I Ea. 1 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
( C-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building ❑Multi-family SFR(3)bath 500.32
Each additional bathh/ki hen 25.02
❑Master builder ❑Other: Fire sprinkler(1 jp 7q.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 14321 ,o_l� Ali,, Catch basin or area drain 18.76
Dr�^ Aij./
(IL_
� Footill,ng
ch line,olinear
trench drain 18.76
2
City/State/Z1P: l_1 C']tC n^c' '
Y.S._S1.1,IV Mann drain(no. ne it tie ) Page5 . 2
Suite/bldg./apt.no.: 12 Project name: Fr Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
e7✓ U-_� --.�112 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: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
--- Clothes washer 25.02
(` C ,., - Dishwasher 25.02
r\'QCill)�,((���Q� `�S Drinking fountain 25.02
__ 1C" Ejectors/sump 25.02
0 PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: TPtk/ LC:I2- kkoQ6 s 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
L •l I , Water heater 37.52
Business name: O r1 rnPn`1 Ir�M_-t dbt� lJ`` C Water piping/DWV 56.29
Address: tr 'S W (St, C:Jlka(Y\bA ham- 1.4ti)� Other: 25.02
City/State/ZIP: "Aroulci Ci- 0 0(oO Subtotal
Phone:(SO3 (0x0'4- ('a.%1 Fax:OW C6(64 . C 4t i Minimum permit fee: $72.50
CCB Lie.: II - �.�. 0 Plumbing Lie.no.: )L �,14 P it,
Plan review (25%of permit fee)
'`�A State surcharge(12%of permit fee)
Authorized signature. \ TOTAL PERMIT FEE /S` 53
Print name: M _ `l��E _1ry,111 Date: CI l 1 00� This permit application expires if a permit is not obtained within 180 days
s►..CcG-t s L after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
C\Building\Permits\PLMU-PermitApp.doc 10/01t09 440-4616T(10/021COM/WEB)