Permit Support Document Plumbing Permit Appl EIVED Q-i ZO'IR
Building Fixtures FOR OFFICE USE ONLY
S E P 01 2020 Received
Cityof Tigard 1- /� PermitN
■ 13125 SW Hall Blvd.,Tigard, Da e By: Z Gt) �X(7 ° S���'�t� J�-'
1IGARD Plan Review
Phone: 503 718 439 F -I��'q'7{7 t, tl Other Permit No.:
Inspection Line: 503.639.41 " ""'�IVISIfl� Date/By:d/69/f �? t„rS:
TIGARD Internet: www.li and-or. ov y Y �// ® SeePege2 1:
g g Netitielelethod: r �� Supplemental Information
TYPE OF WORK /G. 7 J7 FEE* SCHEDULE
IX 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
X I-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building 0 Multi-family
Each additional bath/Wen 25.02
E Master builder 0 Other: Fire sprinkler(J/{d`q ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 1140.3 r I . ') COLD coils--A- -r Catch basin or area drain 18.76
�`r �� �� Drywell,leach line,or trench drain 18.76
City/State/ZIP: 41
^,' �^�y�n�� Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: '(y4. Project name: I).()Sl-{1Ut� Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
E / c , ` „ •.L , Rain drain connector 18.76
�✓� -C V�.YI lJ� 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
Dishwasher 25.02
\LC_ Scan /LULL Alac�s V.• Co Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: IA VUD IC.- rup (LtSO 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
0 APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$_) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/showerpan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
.
c 1 ' -1 `y �.-�-�-"� Water heater 37.52
Business name: OtuL MetJ NW WU - Water piping/DWV 56.29
Address: k402-S W kk` e--OlL1tj10( 12Au,e..9-- 4ta Other: 25.02
City/State/ZIP: itou DAl E , C l- CnOGO Subtotal
Phone:(19,31 (p( r - t�$\ Fax:( (o(P- • ( 4 C ( Minimum permit fee: $72.50
CCB Lie.: t(� _00p Plumbing Lic.no.: 0._43. $3.4?a, Plan review (25%of permit fee)
State surcharge(12%of permit fee) p
Authorized signature. IA _ TOTAL PERMIT FEE J3�c.�rJ S
u Q( ( f This permit application expires if a permit is not obtained within 1 0 days
Print name: aQ �Q Date: l after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
1:0Building\Permits\PLMUJ-PemtitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)