Permit Support Document Plumbing Permit Application
Building Fixtures RECEIVE I FOR OFFICE FSE ONLY
Cityof Tigard Received Nt u
g Date By: �Z�ZZ`ZOZ� Permit No.:MST�j02O ,�)� 11
III • 13125 SW Hall Blvd.,Tigard,OR 97223 DEC 1 5 2020 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: I/13/2 G64( A C LI Other Permit No.:
Inspection Line: 503.639.4175 CITY OFTIGARD
I I i i A R UDate Ready/By: -r 9 lu is: See Page 2 for
Internet: wwwtigard-or.gov Notiiied/Method:ljrr/2/ 410 �� Supplemental Information
TYPE OF WORT. UILDINCi DIVISION FEE* SCHEDULE
}'New 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 R.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
/6 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
/❑Accessory building El Multi-family
SFR(3)bath 500.32
-- - Each additional bath/kitchen 25.02
IDMaster builder 0 Other: Fire sprinkler(.,,W1.ft.)\\SO Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: ([.f;3C-RD b�.�{() j t� (�;11.� i �� Catch basin or area drain 18.76
City/State/ZIP: \ `G 0 di l�10(00 Drywell,leach line,or trench drain 18.76
Footing drain(nn linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name: r -� ,
V Manufactured home utilities 50.03
Cross street/directions to J site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
(n7� 1 ���l i V� n g Water service(no.linearft.:_) Page 2
l
Subdivision: q�t, SfV�_Ln TE Lot na.: L Fixture or item:
Tax map/parcel no: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
-- -- _ - - Clothes washer 25.02
C.
Dishwasher 25.02
Lk. `. , C
4.. Q . 0cA(1 If-_a�c Drinking fountain 25.02
Ejectors/sump 25.02
0 PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: 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
0 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/basin/lavatory 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
Business name: Water heater 37.52
u�,kcp--11pQiRill
i]i.�, NU' (k�_J( L A . 11 Water piping/D W V 56.29
Address: `1 Li) 11 J1 1✓�At 1 jm\�� V {i. 1-k. Other: 25.02
City/State/ZIP: Tit jadd L.I-- Yij0� Subtotal
Phone:(( )co '1 l� Fax:(! j '4 C.c q{1 Minimum permit fee: $72.50
/� Plan review (25%of permit fee)
CCB Lic.: (1 7 ,�tolumbi Tic.no.: ZK). 1�
State surcharge(12%of permit fee)
Authorized signaturA t, TOTAL PERMIT FEE
Print name: ` 1This permit application expires if a permit is not obtained within 180 days
Q `lb Date: (j.�It-1 I)n r after it has been accepted as complete.
w-� *Fee methodology set by Tri-County Building Industry Service Board.
tlBuildingWermits1PLMU-PermitAppdoc 10/01/09 440-4616T(10/02iCOM/WEB)