Permit Plumbing Permit APPli EIVED a l )4) -la
Building Fixtures FOR OFFICE USE ONLY
Cityof Ti and SEP 01 2020 Received p /n
i� _ • 13125 SW Hall Blvd.,Tigard,OR 97223 Date/By: L/Z./7 .GI/Q Permit No ^� zo.-aoi 1J
Phone: 503.718.2439 Fax: id1 V8 60TIGARD Plan Review
DateBy: q f J be AL(f) Other Permit No.:
TIGARD Inspection Line: 503.639.4l JILDING DIVISION Date Ready/By: C� z� .� �a �1u%i, 65 See Page 2 for
Internet: www.tigard-or.gov Notified/Metlrod: / Ira'
Supplemental Information
TYPE OF WORK ePv1,4-j- 7N1r FEE* SCHEDULE
New construction 0 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
NI-and 2-family dwelling ❑Commercial/industrialSFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional batichen 25.02
❑Master builder ❑Other: J/
Fire sprinkler(r!Y q.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: t4214 CI. \ 6 OLD row 'r.PL Catch basin or area drain 18.76
Drywe�en RAID Footing
1,leach line,or trench drain 18.76
City/State/ZIP:
p �-, Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: 1(�S Project name: Q..YJSV Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
bL.G /�, t , - 1A.L i 10J Rain drain connector 18.76
`-C lA.1Il 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
,[ C2...
t " f\ (/ Dishwasher 25.02
"
5,� `fit(\ \ a -O(,S Y' Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: -\ P4.WC I A 10Q ViSu� Fixture/sewer cap 25.02
J�=�a: 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:S ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/Slate/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: 0 ��� � 3\-- Kuj' D } ea,_
Water piping/DWV 56.29
Address: togs LA.) IST ea a ,
,/�t1i1- OAS SK_ K(t`i Other: 25.02
City/State/ZIP: 11230 -D RLE_ di__ t(40(o0 Subtotal
Phone:(S)3 t0 tc:j.4 4' .7, Fax:()3 c0c,'q q° q I Minimum permit fee: $72.50
CCB Lic.: I,_ lambing Lic.no.: a�, tp.i"l T Plan review (215%of permit fee)
State surcharge(l2%of permit fee)
Authorized signature: TOTAL PERMIT FEE t/3� s
Print name: Yl�i� jy 1 Date: This permit application expires if a permit is not obtained within l8 days
�G 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/COMRVEB)