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Permit , mod / h City of Tigard • COMMUNI'TY DEVELOPMENT DEPARTMENT NT . 11 0/1/''j 4 V I. Request for Permit Action 1114 r I t;A€t h) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www,tigard-o.r.gov TO: CITY OF TIGARD RECEIVED Building Division JUN 2 3 2020 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 '1'igardBuildingPermits@t kr�flYagolIGARD BUILDING DIVISION FROM: r Owner ❑ Applicant ❑ Contractor ❑ City Staff Check(V)one REFUND OR r Name: 1 - INVOICE TO: , l us;necs nr lndividu;a) ' G% , /_ 1. /'C'` j�; ''1 p � �. P,: ° Ma' ing.Address: e.V.,/ j t . 4/. tki_ y '.r ✓ City/State/Zip: f °1 �+/ r '''; . I' ./ s 2 Phone No.: 'C;>'.' 2 — 2/ — - ,,,� 3 e`4°: — 7 _ .PLEASE ACTION FOR THE ITEM(S) CHECKED (✓): CA .:L/VOID PERMIT APPLICATION. ® REFUND PERMTT FEES (attach copy of original receipt and provide explanation below). I I INVOICE FOR FEES DUI:; (attach case fee schedule and provide explanation below). fV Permit #: - 17* ) Site Address. or Parcel #: �'' <-j �,1 � �. Project Name: (�„��� (,.- „� � /�,,�. < j Subdivision Name: l.ot #: NAT K; C J /f / d rr . ,, ' ,1-,,�, `" ,tam",t e: , Y at — date: C�'=-9 .-,— 0 * C— 1 Print Name: .,G ,,,,,+ % e4 ' y t Refund Policy I. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • ,\ny fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via I S postal service. 3. Please allow 3 4 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: Date 6 / / _ y 4(.72 Route to Records: Date,l a2j By I/ Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date,;t / J By, e Parcel Tag Added: Date 13v I:\Building\I1on„s\ReyIermitact;on,_ 8,doc Plumbing Permit Application Vey i t Building Fixtures Fou OFFICE use 0N1.1 City of Tigard RECEIVED REEiew D r _ PermitNo.:III 13125 SWHalBlvd.,Tigard,OR 97223 ,am Phone: 503.718.2439 Fax: 503.598.19CAN Dto/By 2020 Date/By: Other Permit No.: T I(i A R D Inspection Line: 503.639.4175 Date Read/B Internet: www.tigard-or.govY o Iur;s: Information See Pent for CI • : L.■ Notified/Method: ,-, Supplemental ❑New construction 0 Demolition For special information use checklist Description I Qty. I Ea. I Total ddition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) SFR(1)bath 312.70 ❑ 1-and 2-family dwelling 5}-CommerciaUindustrial SFR(2)bath 437.78 ❑Accessory building ❑Multi-family SFR(3)bath 500.32 ❑Master builderEach additional bath/kitchen 25.02 0 Other: Fire sprinkler( sq.ft.) Page 2 Site utilities: Job site address: /41 it '7 3 y 5�.�� JJ' 'Li i Catch basin or area drain 18.76 pDrywell,leach line,or trench drain 18.76 City/State/ZIP: -1"(sa U� q?-227 Footing drain(no.linear ft.:_) Page 2 Suite/bldg./apt.no.: /•--41 I Project name: e 610 11Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 6 e ttti../- f tG,C4-c VIA/ Rain drain connector 18.76 Sanitary sewer(no.linear ft.: ) Page 2 Storm sewer(no.linear ft.:_')�i Page 2 Water service(no.linear ft.:A_a .' / Page 2 6a.<y Subdivision: I Lot no.: Fixture or item: 1 / Tax map/parcel no.: Backflow preventer 31.27 Backwater valve 12.51 A Clothes washer 25.02 )I JJ v�Jale✓ --"er fi ct . Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 Expansion tank 12.51 Name: v rpt Vtp fl Fixture/sewer cap 25.02 J 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 Interceptor/grease trap 25.02 Business name: u A (.e OK- or)+ Uµ LizMedical gas(value:$ ) Page 2 Contact name: tit%1 RoofPrim 12.51 eo � Roof drain(commercial) 12.51 Address: Sink/basin/lavatory 25.02 City/State/ZIP: -2 �..N� VI' Solar units(potable water) 62.54 Phone:( 6 0 t. 5 7-'% Fax::( ) Tub/shower/shower pan 12.51 E-mail: c0in 1.6,1 c - g �itte 4 , vi,v le4"5"... c Urinal 25.02 . a...- • Water closet 25.02 Water heater 37.52 Business name: 5M_ � �- = Water piping/DW V 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Phone:( ) Fax:( ) Minimum pennit fee: $72.50 7] ,,,J CCB Lic.: l f y�7,7 Plumbing Lic.no.:P� /Q _ Plan review (25%of permit fee) r` State surcharge(12%of permit fee) Authorized signature: 7 V`51� TOTAL PERMIT FEE FL ,Th Print name: (if^/il ___A, t /1 Date: 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. I:\Building\Permits\PLMu-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)