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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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)