Permit (2) City of Tigard • COMMUNITY DEVELOPMENT DI P A1t"I 1 N'1 4:0
11 0/4/7/
3 Request for Permit Action
T I G A RR CD 13125 SW Hall Blvd. • 'Tigard, Oregon 97223 • 503-718-2439 • wvv=w.ti m td or.=ov
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@ti ikikako3IGARD
BUILDING DIVISION
FROM: 1, Owner ❑ Applicant ❑ Contractor ❑ City Staff
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REFUND OR Name: j
INVOICE TO: (t usincss or Individual) 1 •- r'`G.�- ( ., flir '�--
Mailing.Address: ,/"� /4/4" 72,442
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City/State/Itp:
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Phone No.: `" `'� ` 6 .Z/ %' L`✓; - 7' 0
EASE ACTION FOR THE ITEM(S) CHECKED (✓):
Cif ,L/VOID PERMIT APPLICATION.
REFUND PERMI.I FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: ,Ao -006?) 1 1Ae it' "1 d-'6t)D/7'
Site Address or Parcel #: 7 fJf "
94,
Project Name: q- z
Subdivision Name: Lot #:
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i to e:• Date: "
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Print Name: ,,✓' / �.
Refund Policy
I. 'the city's Community Development Director,Building Official or City I?ngineer 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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°l0 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 US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date "F y j, J. Route to Records: Dater ®3/ By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date,gl / / By,di f Parcel Tag Added: Date By
I:\Building\I urns\RegPerrnit;\ction,._(21l lR.,loc
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Plumbing Permit Application 0,2 I
Building Fixtures FOR oFl l( l: t e O 1.1
City of Tigard RECEIVED Received C
Ill 41 13125 SW Hall Blvd.,Tigard,OR 97223 Date/By: P I. L it fir. Permit No.: � Afr
p�
Plan Review 041-1.,
ti Phone: 503.718.2439 Fax: 503.598.190AN 9 2020
Inspection Line: 503.639.4175 Date/BY: Other Permit No.
l I., 1 i 1) pDate Ready/By: Jug H See Page 2 for
Internet: www.tigard-or.gov Cl • A. •tl Notified/Method:
411 S plementai Informal/on
❑New construction
❑Demolition For special
p information use checklist
P.P. •ddition/alteration/replacement 0 Other: Description Qty. Ea. Total
New 1-2-family dwellings(includes 100 ft.for each utility connection)
SFR(1)bath 312.70 J
❑ 1-and 2-family dwelling
PCommercial/industrial SFR(2)bath 437.78
0 Accessory building 0 Multi-family SFR(3)bath 500.32
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
1.;' Site utilities:
Job site address: /0 7 3 s 5,..j L,t / Catch basin or area drain 18.76
City/State/ZIP: T-,Sa q- 23 Drywell,leach line,or trench drain 18.76
Suite/bldg./apt.no.: _ I Project name: 7/21 Footing drain(no.linear ft.: ) Page 2
L7,e s10 Manufactured home utilities 50.03
Cross street/directions to job site: Manholes
_ 18.76
6"t r G Vikil Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:All 2 ' / Page 2 6)Subdivision: I Lot no.: Fixture or item: +
Tax map/parcel no.: Backflow preventer 31.27
Backwater valve 12.51
New W041_, ,�J„Vt GC Clothes washer 25.02
� Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Expansion tank 12.51
Name: v v-q I Fixture/sewer cap 25.02
Address: Floor drain/floor sink/hub 25.02
Garbage disposal 25.02 City/State/ZIP:
Hose bib 25.02
Phone:( ) Fax:( ) Ice maker
12.51
},, Interceptor/grease trap 25.02
G , . tcob t u Medical gas(value:$ ) Page 2
Business name: t,,OiAt(� OK_ '
Contact name: el.Tot, L 1• Primer 12.51
' rrJ
Roof drain(commercial) 12.51
Address: tier, sm., A,i,_ ':
Sink/basin/lavatory 25.02
City/State/ZIP: P' Solar units(potable water) � 62.54
Phone:( 6 0 Ct ry-7-•O Fax::( ) Tub/shower/shower pan 12.51
E-mail: coo �� t� � (P L 'l i �MLe.c c Urinal 25.02
CONTRACTOR i Water closet 25.02
Water heater
Business name: _ _ 37.52
�' S�� 4` blA Water piping/DWV
Address: 56.29
Other: 25.02
City/State/ZIP:
Subtotal
Minimum permit fee: $72.50 7) �t
Phone:( ) Fax:( )
CCB Lic.: l Plumbing Lic.no.:���� Plan review (25%of permit fee)
0-1...-"1 State surcharge(12%of permit fee) Ir. "7�Authorized signature:
f -.�,� 1 TOTAL PERMIT FEE 1.1 7 L
Print name: -" 1 ____1f yt d�J V/•J Date: This permit application expires if a permit is not obtained within 180 days
1 after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
L\Budding\Permits\PLMU-PetmitApp.doc 10'01/09 440 1616T(10/02/COM/WEB)