Permit Support Document Plumbing Permit Application
Building Fixtures RECEIVE , FOR OFFICE USE ONLY
City
of Tigard
i and : Received
Date/By: ,^I2 '2 200\1 Permit No.:
YS1-20�..00t4�
• P13ho1ne:S5W0 3H7a8B2l4v3d9.,TiFaraxd,5OR.599782213960DEC 15 2020 Plan Review
Date/By: 1/13 f Z Oal t AC61 Other Permit No.:
T I GARD Inspection Line: 503.639.4175 Date Ready/By: ® See Page 2 far
Internet: www.tigard-or.gov CITY OF TIGARD z/�, <Qa 3
Nonfied/Nlcthod: t t i Supplemental Information
TYPE OF woiu IJILDING 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 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
ElAccessory building ❑Multi-family SFR(3)bath 50032
Each additional bath/kitchen 25.02
❑Master builder 0 Other: Fire sprinkler(1.040q.ft.)\\) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: Il 2 t(\. U.) 64006 LoPi-c 1 - Catch basin or area drain 18.76
City/State/ZIP: 1 `C) CIA) Q(L r1 Drywell,leach line,or trench drain 18.76
2' Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.:@1 Project name: ���
IJ\� �-L'�1c 3� Manufactured home utilities 50.03
Cross street/directions to b 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: c_QSh a�( FD c j o D a Lot no.: (4`3 Fixture or item:
Tax map/parcel no.'. -�` Backflow preventer 31.27
DESCRIPTION OF WORK - Backwater valve 12.51
-- - -- --- Clothes washer 25.02
r.
��''JJ ��;; Y Dishwasher 25.02
P<<'t_> ` 7'�-'1i\, �\1 , CA�\ ! - .C) Drinking fountain 25.02
0 Ejectors/sump 25.02
❑ PROPERTY OWNER 0 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 0 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:tY Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
p p Water heater 37.52
Business name: 1.:`�c\cc ('`k� ) ( �,j(. ``.dc(�y-`fir WaterpipinglDWV 56.29
Address: t�% `fly* Qi(_ ( tZm'cipt V-'\1J'�Q""It}'Ivt6V.,\' Other: 25.02
City/State/ZIP: ;Q (1,, 1a��99.� C1' Subtotal
Phone:( Fax: Minimum permit fee: $72.50
• Q Plan review (25%of permit fee)
CCB Lic.: l}'2 'Z �� Itunbing Lic.no.: 2 t�' P>
State surcharge(12%of permit fee)
Authorized signatptN � o TOTAL PERMIT FEE
Print name: A 1 �._]M ` Date: (7 '4170 1^ This permit application expires if a permit is not obtained within 180 days
-�`li !� after it has been accepted as complete.
"Fee methodology set by Tri-County Building Industry Service Board.
I:\Building'Permiis'PLMU-PermitApp doe 10/01/09 440-4616T(10/02/COM/WEB)