Permit Support Document Plumbing Permit App1 DELVED Q t_2'' t3
Building Fixtures q FOR OFFICE USE ONLY
City of Tigard SEFp 01 2020
OL0 Deceived 9-7 /ZO PermitN e
■ 13125 SW Hall Blvd.,Tigard,a' Date/By: -/ 4) �l`1ST7.�Zo�lH O
14 S, Plan Review
Phone: 503.718.2439 Fax Oi y Other Permit No.:
Date/By: p� f{f ef0 fZL�I!
Inspection Line: 503.639.41; ti U DIVISION Date Read B`I t ��\ �(y' tur's H Sce Pa c2for
TIGARll Internet: www.ti and-or. ov y yt W/Cki rVl-' Supplemental Information g g Noti£ed/Me[hod: /
TYPE OF WORK t7.19-et- 7/f e- FEE* SCHEDULE
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
0 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
El Accessory building ❑Multi-family
----- Each additional bath/kitchen 25.02
❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
1 s'4 sup l 6 fy p D A T�p Catch basin or area drain 18.76
Job site address: ILA c J W lJl 4 1 f .
DrCity/State/ZIP: 1 le n' ..t' 1' Q -224 Footingowe draileach line,or trench^ 1 ge 2
drain(no.linear ft.: � vX Page 2
Suite/bldg./apt.no.: Project name: ,^)trt
ryIL Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
lb. A f 1 n ,1,. lcD2r Rain drain connector 18.76
�.�.1�l.0 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
,(� , p Dishwasher 25.02
SD�(,(\�(�� p\awls- \-Q,b Drinking fountain 25.02
T YY Ejectors/sump 25.02
0 PROPERTY OWNER I 0 TENANT Expansion tank 12.51
Name: 1-AN LO Q lu04_,V. .SDO 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
tV �-� Water heater 37.52
Business name: Dt\i .LoP�lo-C �&A L�t„�\1
I fI, /�,� �/ Waterpiping/DWV 56.29
Address: 1o�-S�yI^tI),!RkS'tUQ��. COUJ1EkAr Q&V€L 1„tW`F Other: 25.02
City/State/ZIP: irtok l YPI.L q-�10f Subtotal •
Phone:�J S0(0"; `'-' %.\ Fax:W-5)C:AcR a$G14 Minimum permit fee: $72.50
CCB Lie.: \\22 W umbing Lic.no.:a(p. Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: �`VVV r
1 TOTAL PERMIT FEE 1.3‘ 53
Print name: ),,�•�� e ` Date:lit' ( 12.070 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
PABuilding/Permds\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM]WEB)