Permit Support Document 1,/d / t.)
, ..7City of Tigard • COMMUNITY DEVELOPiMENT DEPARI TENT 0,72/ �n
3 ' Request for Permit Action
T I I,.i to IL D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.l,ovr
TO: CITY OF TIGARD RECEIVED
Building Division JUN 2 o 2020
13125 SW I fall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 'I'igardBuildingPertnits cr tiAFIYa IGARD
BUILDING DIVISION
FROM: Owner ❑ Applicant ❑ Contractor ❑ City Staff
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REFUND OR Name:
INVOICE TO: , 1 sines,or Indnvidnag A A • C i' C' L // q'
:2-
' .,
Mailing.address: ,,..4/a.`5/e, '' ii' /ram' 17,4'.; 47. " '
72.162
City/State/'Zip: e94 , /` al '' , I
Phone No.: C j[ '" ' `" . 2/ ' 3' 7 e-'"L'� ;` �,O. . 7 '
ACTION FOR THE ITEM(S) CHECKED (1):
2, i L/VOID PERMIT APPLICATION.
il REFUND PIRMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
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Permit #: /"
Q 17//KAI
Site Address or Parcel #: ? 3 i �L . , '
,�'' �/ ' 7; : .. -
Project Name: C�-�=�;�--� . 1'�-� '/�"
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Subdivision Name: Lot #:
11---; 4e,73 ° t'f''' _ ,
4.7
+ ilm;Iture: .,,.., . Date: e., 2- C-) :7 c,,,
Print Name: ,,r✓'I �G" , kit
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Refund Policy
1. .rhe city's Community Development Director,Building Official or City I�.nginecr 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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%of the application or permit fee for issued permits prior to any inspection requests.
2. .All refunds will he returned to the original paver in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date , 2, ) y <% Route to Records: Dated / / By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date,,g�j'/�f By,�D Parcel Tag Added: Date By
I:ABuilding\Forms\RciPcrmi Achion,_(2(311H.doc
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Plumbing Permit Application -« V o ! b
Building Fixtures FOR OFFICE USE 0yl l
City of Tigard Received
DateB Permit No.:
RECEIVEDy: / p�^,II 13125 SW Hall Blvd.,Tigard,OR 97223 3/ �abdO-ai -s
g Phone: 503.718.2439 Fax: 503.598.196 ANDate/By:
Plan Review
9 2020Da Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 Date Ready/By: 7uris: H See Page 2 for
Internet: www.tigard or.gov CIT . ••• Notified/Method: ` Supplemental Information
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❑New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. ( Total
le •ddition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
SFR(1)bath 312.70
ID1-and 2-family dwelling mmercial/industrial SFR(2)bath 437.78
❑Accessory building El Multi-familySFR(3)bath 500.32
El Master builder Each additional bath/kitchen 25.02
❑Other:
Fire sprinkler( sq.ft.) Page 2
1. Site utilities:
"�' 1r ���j`L� / Catch basin or area drain 18.76
Job site address:
10 7 3s 5-J
/ A q�22� Drywell,leach line,or trench drain 18.76
City/State/ZIP: .("'`Sa+p� 7
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: , __ I J Project name: 6€ 5IO tA Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
6° f�UC4G 411 Rain drain connector 18.76
/ Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: ) t Page 2
Water service(no.linear ft.:/5 2 '. / Page 2 62
Subdivision: I Lot no.: Fixture or item: 1
Tax map/parcel no.: Backflow preventer 31.27
Backwater valve 12.51
Clothes washer 25.02
_JJQU/ ki Ja ✓ - 'rtj1 <C
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Expansion tank 12.51
Name: v ra l?fl 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
Interceptor/grease trap 25.02
Business name: 1, (� t3K, 44- .. •_ / um, i 1,u Medical gas(value:$ ) Page 2
Contact name: ,
Primer 12.51
QRoof drain(commercial) 12.51
Address: .k Sink/basin/lavatory 25.02
-
City/State/ZIP: ..,_ VT" Solar units(potable water) 62.54
Phone:( �J
CO a , ('--�a S Fax: :( ) Tub/shower/shower pan 12.51
E-mail: 1 ,, Urinal25.02
ail: 0 i et G
Water closet 25.02
CONTRACTOR
-. Water heater 37.52
Business name: t5�Je �� a 1mii-C._ Water piping/DWV 56.29
Address: Other: -
. 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( ) Minimum permit fee: $72.50 -7p .57.)
CCB Lic-: Plumbing Lic.no.:PB ��/� Plan review (25%of permit fee)
`�/ 6 State surcharge(12%of permit fee) '-7
Authorized signature: s���1 TOTAL PERMIT FEE 'y l. ) )
Print name: t,, r� 1 '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-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)