Permit Support Document Plumbing Permit Application� r 91
Building Fixtures 1 l ED FOR OFFICE USE ONLY
Cityof Tigard Received`n n z^
25 g DEC 1 5 2�20 Date/13y: L L ��(.� �� Ycrnut No.: T�J(s�-�`��
4 13125 SW Hall Blvd.,Tigard,OR 9'7223 w
Plan Review
Phone: 503.718.2439 Fax: 503.5981 j§ Date/By: J/LI/Vet21 4(�(!1 Other Permit No.:
I Inspection Line: 503.639.4175 �I OFTIGARD ./„41. 7j) HI See Page 2 for
t A��D Internet: www.tigard-ongov I Date Ready/By: {�l[�r and
BUILDING DIVISION Notified/Method: Supplemental Information
TYPE OF WORK FEE*SCHEDULE
$New construction ❑Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement ❑Other: _ _ New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
11-and 2-family dwelling IDCommercial/industrial SFR(2)bath 437.78
ID Accessory buildingSFR(3)bath 500.32
❑Multi-family
- -- Each additional bath/kitchen 25.02
❑Master builder ❑Other:
Fire sprinkler('Oleg.ft.)\\e 0 Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: tl I,'1 j ( Catch basin or area drain 18.76
t, `1.�=' ( Lb 0.0 1- `T 4.-
(� �} Drywell,leach line,or trench drain 18.76
City/State/ZIP: r-kl(IND CV- Cl.-72
p�� q ���� Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: of .� Project name: Cif) K , Manufactured home utilities 50.03
Cross street/directions injob site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: 1. , \nj i Frini-Q,4 I Lot no.: ri(--1Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
�,�(� n L (� (�1�/'� J� Dishwasher 25.02
. � /tf-�'7 I ll� -Q N� �I(JS I 1` Drinking fountain 25.02
'J Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
Floor drain/floorsink/hub 25.02
Address:
Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$_) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: 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: - o��Q i'-f o- �)J (I�o L I CCJ.{J -
W Water piping/DWV 56.29
Address: 107S- LJ ';-4.1- CoLti ll CZ.
0,0V9, ]- 14 Other: 25.02
City/State/ZIP: '' I(1GL� c Q CZ. 0'4 (OtO Subtotal
Phone:(,g)3 ��..}- I _}. Fax:('may Cob_7 ( ?q i Minimum permit fee: $72.50
9p_� Plan review (25%of permit fee)
CCB Lic.: [1 7 Z0 Plumbing Lie,no.: ato 9.24
State surcharge(12%of permit fee)
Authorized signature: TOTAL PERMIT FEE
Print name: I\1 Q d m1(��,\/ Date: n. 4 7�y l D This permit application expires if a permit is not obtained within 180 days
y \ after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
NBuilding\Pera ts1PLMU-PerseitAppdoc 10/01/09 4404616T(10/02/COM/WEB)