Permit Support Document Plumbing Permit ApnlifittEIVED ,-6
Building Fixtures FOR OFFICE USE ONLY
City of Tigard S E P 0 12020 Received ss _
. Date/By: 9/GI 4 G' Permit Npp,,,,�� u y
13125 SW Hall Blvd.,Tigard,OR 97223 'LS I ���_/ "
Phone: 503.718.2439 Fax:
11437V.OBbTIGARD Plan ReviewDate/By: 44//af,10 AGCn Other PermitNo.:
T I G A R D Inspection Line: 503.639.41 BUILDI NG DIVISION Date Ready/By: Q /n1 7urisj'� ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method:Yf �ZO /!l O 14 Supplemental Information
TYPE OF WORK er7'07e---- y-DA/7 FEE* SCHEDULE
[XNew construction 0 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
[41-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional bb�a p/ tchen 25.02
❑Master builder III Fire sprinkler U aO&q.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: mZ$(c, 6uW CAsv leg_ Catch basin or area drain 18.76
Drywety �(1 W J t Footing
1,leach line,or trench drain 18.76
City/State/ZIP: (�
/ Footing drain(no.linear ft.: ) Page 2
Suitc/bldg./apt.no.: 10 l0 Project name: NC Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
tl (, /1 ( ( I[)j^ Rain drain connector 18.76
l T �/�. `�`J'�J Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2 1
Water service(no.linear ft.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
kt _ic)4 OCkle QI ( 4(p Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER 0 TENANT Expansion tank 12.51
Name: W/_ 110�Qi SL N Fixture/sewer 25.02
T Floor drain/floor sink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) 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: [Teti��P m(1(�1 o��- r ..�
t�-"U v t/ -�Co� Water piping/DWV 56.29
Address: ��S w �t �C COW Olt, A Q jVet 4•((,.y Other: 25.02
City/State/ZIP: q 1 )( 4 peril- cl' -O c 0 Subtotal
Phone:(6L�t�^-�x 6(rc 1 Fax:(�•• Coto`. CI i,co Minimum permit fee: $72.50
t7�') sO�O� \�$+
CCB Lic.: 1 i. P mbing Lic.no.:�• �P1' Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE 4%rj
Print name: ll ^ w^ ^ Date: This permit application expires if a permit is not obtained within ISO days
v ( after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:1Building\Pcrmits`PLMU-PermitApp.doc 10/01/09 440-4616T(I0/02/COMWEB)