Permit Support Document Plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
Cityof Tigard DEC 15 2720 Received\2I Z � �� ��Date/By: Permit No.:te ' 2412/0-•op\ { 5
111 • 13125 SW Hall Blvd.,Tigard,OR 97223
Plan Review Phone: 503.718.2439 Fax: 503.598.19 Date/By: i i 3/ O 2 i A C6 Other Permit No.:
Inspection Line: 503.639.4175 CITY OF TIGARD
I C 6,1 R D Date Ready/By: / 7 9 0 la See Page 2 for
Internet: wtivw.tigard-orgov BUILDING DIVISION. Notified/[olethodG/ff/
BUILDING Supplemental Information
TYPE OF WORK FEE* SCHEDULE
}New construction ❑Demolition For special information use checklist.
Description I Qty. En. I Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 R.for each utility connection)
CATEGORY OF.CONSTRUCTION SFR(1)bath 312.70
[ 1-and 2-family dwelling CICommercial/industrial SFR(2)bath 437.78
El Accessory building SFR(3)bath 500.32
g 0 Multi-family
---- Each additional bath/kitchen 25.02
❑Master builder ❑Other. Fire sprinkler( WI.ft.)\L \ Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 4_VA.) c -A.;j , iL 0 (1 .�-S4 r� Catch basin or area drain 18.76
�� t Drywell,leach line,or trench drain 18.76
City/State/ZIP: MC-.. C*INA. - (t 2`Z! { Footing drain(no.linear ft.:_) Paget
Suite/bldg./apt.no.: (L Project name: -�, ��
oL I 1 On 0'1C. Manufactured home utilities 50.03
Cross street/directions hijlob 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: EASti(1 I Lot no.: cf2 Fixture or item:
Fax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
// [� n �/ /� q Dishwasher 25.02
1 t( � (-4)61 (3 J l -� K g�) to Drinking fountain 25.02
1 Ejectors/sump 25.02
0 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
❑ 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
- Water heater 37.52
Business name: Ie � 11�QS\� �\ i� Jr ���
^-� l \co Water pipingDWV 56.29
Address: \0 • -S 10 cjc Q)
(ph{(>\, a aveQ,ttal Other: 25.02
City/State/ZIP: ''Q,Q i ICU.R 0 a_ Ct OCLID Subtotal
Phone:(q1,13 (nk:J ( 'E,1 Fax:( Ij 004 ti V('1 Minimum permit fee: $72.50
CCB Lie.: t 1' 7 7 Plumbing Lic.no.: it".ci.„,-4 et, Plan review (25°e%of permit fee)
State surcharge(12/n of permit fee)
Authorized signature: TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180 days
Print name: �j f�\t Date: `�_ `l ���� after it has been accepted as complete.
*Pee methodology set by Tri-County Building Industry Service Board.
1:1Building\Permits1PLMU-PermitApp.doc 10/D1/09 440.4616r(10/02/COM/WEB)