Permit 1,/ / 6
City of Tigard •• C;OAIiMUNI'I Y DI:M'BLOPMLN'I' DEP.\R'I'MI N'I' 0r� / ,A)8 : Request for P7errmt Action
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TIC,;A R D 13125 SW I tall Blvd. • Tigard,igard, Oregon 97223 • 503-718-2439 • www.t.iyard ongov
TO: CITY OF TIGARD RECEIVED
Building Division JUN 2 3 2020
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 5(I3-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@ti c kTIGARD
BUILDING DIVISION
FROM: ►1, Owner ❑ Applicant ❑ Contractor ❑ City Staff
(;heel,(1 unc
REFUND OR Name: AA
nd,i ) , i` ' G ' 4 - L `I 2 //471111---
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Mailing.Address: /d 2. -/e..) V' 41_ 4 _v...., r ' 144 ,.-.
City/State/lip: Pe 4
" ` ✓ C '27,; . j' J
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Phone No.: , ` , " 2/ 2.--de,..77 --L `""- .' t! .- 72;70
ACTION FOR THE ITEM(S) CHECKED (1):
is ► ::L/VOID PERMIT APPLICATION.
Illi REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: iQ ,d`1Q0 .) � 12- 1?if c ' ire_ /ol/rj�nove-i k /7'�/ar/ld.)
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Site.Address or Parcel #: �'0 3 `'jam +�f'�'` p : l� ,• ,
Project Name: Cam. 7 1�' L . , " ; G
Subdivision Name: Lot #:
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;�tln.lure: 4-4,, Date: : 0 cl„,
Print Name: TT' � ! �'' r' e" , ' y
Refund Policy
I. The city's Community Development Director,Building()fficial or(:ity Ingineer may authorize the refund of
• Any 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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"/o 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 VS postal service.
3. Please allow 3-4 weeks for processing refund requests.
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Route to Sys Admin: Date 1,_ y 0 .,./. Route to Records: Date,2 a,2/ By
Refund Processed: Date I3y Invoice Processed: Date By
Permit Canceled: Date� / 13y,d0 Parcel Tag Added: Date By
11m 1:ABuilding\Porrs\Rc 1Pcrmit:Action- (2(i. tt.doc
Ii
Plumbing Permit Application V® / i
Building Fixtures RECEIVED
City of Tigard Received I
Date/By:II iii 1�5/, Permit No.: 2� L ' �
13125 SW Hall Blvd.,Tigard,OR 97223 !!! ✓s kp
Phone: 503.718.2439 Fax: 503.598.19C$AN Plan Review
2020 Date/By: Other Permit No.:
T I G.�R n Inspection Line: 503.639.4175 Date Ready/By: luris;
Internet: www.tigard-or.gov H See Page 2 for
CIT • A E.a Notified/Method: X-C, Supplemental Information
❑New construction 0 Demolition For special information use checklist
11.3 Description I Qty. I Ea. I Total
ddition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
(;, SFR(1)bath 312.70
17;
❑ 1-and 2-family dwelling
��Commercial/industrial SFR(2)bath I 437.78
❑Accessory building ❑Multi-family SFR(3)bath 500.32
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
Site utilities:
Job site address: /0 7 3 3- S� h7u'Lt / Catch basin or area drain 18.76
City/State/ZIP: Tt SQ y /(Th q 7-`Z'fi3 Drywell,leach line,or trench drain 18.76
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: el_t 1 I Project name: e e 610
Val Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
6 e 1r.� f ter:c iki Rain drain connector 18.76
/ Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.:_.) Page 2
Water service(no.linear ft.:/5_?, •' / Page 2 C )
Subdivision: I Lot no.: Fixture or item: 1
Tax map/parcel no.: Backflow preventer 31.27
Backwater valve 12.51
25.02
Clothes washer
JIQU/ v�Jat�e✓ -5ti°r1/i ce -
• Dishwasher 25.02
- -
- Drinking fountain 25.02
Ejectors/sump 25.02
Expansion tank 12.51
Name: w trekt.(f Fixture/sewer cap 25.02
Address: J Floor drain/floor sink/hub 25.02
Garbage disposal 25.02
City/State/ZIP:
Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
ir-
g ar.4,� ,.. Interceptor/grease trap 25.02
Business name: u 016•(( , • / ` i Liz Medical gas(value:$ ) Page 2
Contact name: T, T k�1�, ) Primer 12.51
Address: tie b „,„.3 /�!„t,t ` Roof drain(commercial) 12.51
Sink/basin/lavatory 25.02
City/State/ZIP: � �, -
Solar units(potable water) 62.54
Phone:( CO Gj,1-�� ^Fax::( { ) Tub/shower/shower pan 12.51
E-mail: coo 1,s4 („4- g (e !V ,� f (f 44 ,e5 C Urinal 25.02
Water closet
CON' 'RACTO1 25.02
Water heater 37.52
Business name: 4..:___I a .__ -
Water piping/DWV 56.29
Address:
Other: 25.02
City/State/ZIP: Subtotal
Minimum permit fee: $72.50 7) ,5ti
Phone:( ) Fax:( )
CCB Lic.: Plumbing Lic.no.:���/ Plan review (25%of permit fee)
Y State surcharge(12%of permit fee) �_ 70
Authorized signature: f�Z/1 TOTAL PERMIT FEE /') ,
4'f1 ___�
Print name: L t yl,4 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-Permi1App.doc 10/01/09 440-4616T(10/02/COM/WEB)