Permit Support Document Plumbing Permit Application,�C�O�e�
Building Fixtures C FOR OFFICE USE ONLY
Cityof Tigard DEC1 Received `2 2Z ZO2O (\` n l-^O�O-(\02.
` g DED 1 5 2220 DateBy: �'1\ Permit No. `Y� ,(,
,"�i • 13125 SW Hall Blvd.,Tigard,OR 97223
,t' Plan Renew
Phone: 503ine: 439 Fax: 503.598.1 Date/By: i/13/�Oal i ,q6G Other Permit No.:
Inspection Line: 503.639.4175 ultY OF TIGARD
f l G A K D Date Ready/By: See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION NotifiedMethod:47W' / l-' Supplemental Information
TYPE OF WORK FEE* SCHEDULE
CKd New construction 0 Demolition For special information use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
0 1-and 2-family y dwellingSFR(2)bath 437.78
0 Commercial/industrial
ElAccessory building El Multi-familySFR(3)bath 500.32
Each additional bath/kitchen 25.02
❑Master builder ❑Other:
Fire sprinkler( i. q.ft.)\\eo Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 435T, C.1,�� C.iC I� i0 T 'T,.(.il_ Catch basin or area drain 18.76
1 �� Drywell,leach line,or trench drain 18.76
City/State/ZIP: ( `4
L 0(.4
Footing drain(no.linear ft.:_) Page 2
Suite Bldg./apt.no.: 3 Project name: 12_,0C Manufactured home utilities 50.03
Cross street/directions to3 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
y�
Subdivision: y r1 IT
15c)ii,[Q3e - Lot no.: cif..., Fixture or item:
Tax map/parcel no.: .1t Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
q Dishwasher 25.02
i(QJ 'V ,XJ p1 OJIS r- (0 Drinking fountain 25.02
Ejectors/sump 25.02
❑ 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
❑ 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
Business name: - Cott-
WaterWater heater 37.52
"l,E'"_�L--d�{i L(;LS- �-'h�- (�('�(� �. piping/DWV 56.29
Address:�� _ Call m f\k _ALI, Other: 25.02
City/State/ZIP: 1 I -6. l ('10(61() Subtotal
Phone:(95_9 O i:i_ 174-'1 Fax:(t)9 ((Anil- q T411 Minimum permit fee: $72.50
Plan review (25%of permit fee)
CCB Lie.: 1 1 -7 1 bins Lie.no.:
Z�! 2�Q I� �� - State surcharge(12%of permit fee)
Authorized si \re: ({ 1 I TOTAL PERMIT FEE
Print name: ° �J Date: 11 I(�1 70-1Q This permit application expires if a permit is not obtained within l86 days
after it has been accepted as complete.
"Fee methodology set by Tri-County Building Industry Service Board.
I:1 Building\Permits1PLMU-PermitAppdoc 10/01/09 440-46167(10/02/COMIWEB)