Permit Support Document Plumbing Permit Application r%0L-
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Building Fixtures f U
City Tigard and DEC 15 1220 RDate/By: \1d 0%4-Z 2020 NU Permit No.:m.T2 -oc \O5-
III ■ 13125 SW Hall Blvd.,Tigard,OR 97223 n pla Review
• ' Phone: 503.718.2439 Fax: 503.598.196(QITY OF TIGARD DateBRy: 1-13-Pool/ AC A Other Permit No.:
Inspection Line: 503.639.4175 BUILDING
t Date Read iB� 7uir ® SeePa e2fnr
TIG�I:O 0
Internet: www.tigard-or.gov DIW/ISION Natified/Mcthad: �f 40V g� G � Supplemental Information
TYPE OF WORK FEE* SCHEDULE
ANew 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)
y'�/l CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
{� l-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑`Accessory building ❑Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder ❑Other Fire sprinkler( t s ,ft.)\y3s- Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: - Catch basin or area drain 18.76
��� f-��� Ct �� � �� Drywell,leach line,or trench drain 18.76
City/State/ZIP: �1(4 O \ )e- �Z2
L Footing drain(no.linear ft.: ) Page 2
Suite bldg.lapt.no.: aq 3 I Project name: r a V `ii._, Manufactured home utilities 50.03
Cross street/directions to job 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: ] / ''A 'tt [ff I Lot no.: 101 Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
n
t� r - .n ,} Dishwasher25.02
`� + Atd e 1 Hi Drinkinggfountain 25.02
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
❑ 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
CONTRACTOR Water closet 25.02
�p .s P Water heater 37.52
Business name: . LL Q\0T 1 . A>11, 6,'^1 L-L. AC((lY 61 Water piping/DWV 56.29
Address: t1' W Itisct' (c .u. CJ�rta�Q� tib�{t. 1\1�A Other: 25.02
City/State/ZIP: ^to fyL( J `'1 7 L%ln tO 7� Subtotal
Phone:(5D?1 rc)tta- VI Fax:( (C)(Clq- G CLI Minimum permit fee: $72.50
q � Plan review (25%of permit fee)
CCB Lic.: 11 ?.Z`20 lambing Lic.no.: L-Fo ,Z_
State X. surcharge(12%of pemlit fee)
Authorized signature, t TOTAL PERMIT FEE
Print name: {. MN.� Date: 1.2 ^,LY' '1�r1/�_I b�Permit application eapires if a permit is not obtained within 1S0 days
)� \\ F-- after it has been accepted as complete.
`Fee methodology set by Tri-County Building Industry Service Board.
IaBuilding\Permits\PLMU-Perr itApp doe t0/01/09 440-4616T(10/02/COMIWEB)