Permit Support Document Plumbing Permit Application
Building Fixtures rtrEcEIVED
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City of Tigard �� v PemtNo.:�
liql • 13125 SW Hall Blvd.,Tigard,OR 97223 DEC 5 1"`� pate/B an Review
a ' Phone: 503.718.2439 Fax: 503.598.1960 ///3/Qo21 AGem Other Permit No.:
p CITY OF TIGARD Date'Re
Inspection Line: 503.639.4175 Date Ready/By:p � Juris . Ei See Page 2 for
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g g f' Notified/Methodt" //J Z/ AY L -Alt, Supplemental Information
BUlLDIr�i�, DIVISION
TYPE OF WORK FEE* SCHEDULE
IVNew construction ❑Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
g.1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
0 Accessory building 0 Multi-family
- Each additional b:yL'ttchen 25.02
❑Master builder ❑Other: Fire sprinkler( ` t.ft.)»Z� Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 144. 3-7J' ¶-&J ciit t COO--;V ' �j 4Catch basin or area drain 18.76
�City/State/ZIP: m��0� _ ����. Drywell,leach line,or trench drain 18.76
�' (� ��� Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: Wlb a Project name: i3O 1C 11 Manufactured home utilities 50.03
Cross street/directions to lob site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision: rio Vi t( I Crt_9fiA:t1,08c 1 Lot no.: 1.3(p Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
Y( �4 1 '-,0 U t O P (d-n 4-1-(0 Drinking fountain 25.02
1'1' Ejectors/sump 25.02
El PROPERTY OWNER ❑.TENANT Expansion tank 12.51
Fixture/sewer cap 25.02
Name:
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
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basinflavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Peep'>`✓,f n*- NO O L C Waterpiping/DWV 56.29
ON
Address: to , it-Q(.S 4l,t.0 Cii fit\1 k o(_V 1(l. Other: 25.02
City/State/ZIP: ,Cik)j _ CV- allx00 Subtotal
Phone:(cS1,3 ( Co -- I 7.)s0 Fax:( )j l `T G%(4, Minimum permit fee: $72.50
CCB Lic.: 11 Lz_`zo Plum g Lie.no.: 71'J• (�� Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature TOTAL PERMIT FEE
Print name: ` C 3v`,QM I Date:)24114 107,0This 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:\Bnildmg'Permiis'PLMU-PermitApp.doc 10/01/09 4404616r(10f02/COM/WEB)