Permit Support Document Plumbing Permit Application
Building Fixtures F �CE�VE<r, FOR OFFICE USE ONLY
City of Tigard DEC 15 20211 Received\1 /!7\ZbU) Permit No_:MST��-op`Q\
ga 13125 SW Hall Blvd.,Tigard,OR 97223 Date Rev 4`�\
S Plan Review
Phone: 503.718.2439 Fax: 503.598.196Q',I�OF TIGARD DateBy: 1/J 3f20ap I A.Le., Other Permit No.:
T f r,A I.u Inspection Line: 503.639.4175 Datc Rcady/By: oH See Page 2 for
Internet: wwrov.tigard-or.gov BUILDING DIVISION Notified/Method:v/ft/Z'i Sr"' t/ Supplementallnformation
TYPE OF WORK t FEE* SCHEDULE
KNew 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)
r
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑,1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory buildingSFR(3)bath 500.32
❑Multi-family
Each additional)a i en 25.02
0 Master builder ❑Other: Fire sprinkler .)\43 Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: ' I `ZZ ( I A-
Job basin or area drain 18.76
,�n Drywell,leach line,or trench drain 18.76
City/State/ZIP: T\�1 �L() 1-(j C1-4'z�"�
Q Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: kJ0\'31 Project name: (l_ ^�� Manufactured home utilities 50.03
Cross street/directions too 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
L
Subdivision: f't(�k_I .d e . Lotno.:I
Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
�- I \ /'') Dishwasher 25.02
SQo., ,k "i � ) c C [D Drinking fountain 25.02
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
Business name: (r f,, ...,`
Water heater 37.52
�-�r� v�p`' `Q�� ��� IOC, �-����1(Q Water piping/DWV 56.29
Address: �0.S- a itA ,Q�', CC�-�IY\16A �,QQ_ U)A Other: 25.02
City/State/ZIP: TQ e LA(ltau \` q`..E-(,,0 Subtotal
Phone:( 13 (c)( �- \'"f'J Fax: '21 (c)(0'1 ( 'e I Minimum permit fee: $72.50
Plan review (25%of permit fee)
CCB Lic.: n PI ing Lie.no.: 2_cy Y4 14.99
J1\� � State surcharge(12%of permit fee)
Authorized sign r1 - TOTAL PERMIT FEE
Print name: IL q,\(`l C{\ Date: r2, 'li -)Q7O This permit application expires if a permit is not obtained within 180 days
►�,` I� after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I\BuildinglPermits\PLMU-PermitApp.doc 10/tl/09 440-4616T(10/02/COM/WEB)