Permit Support Document Plumbing Permit Application
Building Fixtures RECEIVED FOR OFFICE USE ONLY
Cityof Ti alvd Received \7 ^ c\ 1vVSaT2UZ0- 4
g q� Receive �� ZZ SJ+G.v V Permit No.: 00,O
11 • 13125 SW Hall Blvd.,Tigard,OR 97223 DEC 1 5 2 .0
Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: i/23 ,"i �Gt!11 Other Permit No.:
1.I _A Ill) Inspection Line: 503.639.4175 CITY OF TIGARD
Date Ready/By: Z j JO ra ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method: J'��Z � SO �{�G
!WILDING DIVISION Supplemental Infarmafioa
TYPE OF WO FEE* SCHEDULE
, Jew 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
> -
4,1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
0 Accessory building ❑Multi-family
------- Each additional bath/kl hen 25.02
❑Master builder ❑Other: Fire sprinkler( ft.)\,EC, Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: IL V r, ,1 • C7i.,b OD- 1 r-w- Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
citylstate/z1P TIG NZ J2)
cL G2_Z'4-
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Rp, 3 Project name: ck 8\ k_, Manufactured home utilities 50.03
Cross street/directions allab 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: O Jq L I EaStl x1.cf.* I Lot no.:
00 Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK IIackwatervalve 12.51
---- Clothes washer 25.02
Dishwasher 25.02
44ixf/3 J9I,)()S iL,-(0 Drinking fountain 25.02
Ejectors/sump 25.02
El 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
p � L t I p Water heater 37.52
Business name: 11 UE Gi)l7�({,L- J�0 (-414 (/ (Cc k'.'
�( t' 4, Waterpiping/DWV 56.29
D"�Address: Lk) iVts-l- llfj t,L lO'14.),j'4 viork_L. j.tL/,L Other: 25.02
City/State/ZIP: +QCLL4 d(Uq i (A-- cn��0 Subtotal
Phone:(q. 1 llJ '.4- 1.1- 4A Fax:(a)) (,,, q"4 ` ,( ( Minimum permit fee: $72.50
� ( Plan review (25%of permit fee)
CCB Lic.: 1 2-22c' Plumbing Lie.no.: .Z-� g2"'l PF� State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: City��� Date. 12 I�-t'1 D7,C This permit application expires if a permit is not obtained within 180 days
111------111 after it has been accepted as complete.
'Fee methodology set by Tri-County Building industry Service Board.
I:\Building'Permits'PLMI7-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)