Permit
Ytumbing Permit Application
Building Fixtures i FOR OFFICE USE ONLV
City of Tigard 0 L Izeeeived
•J Date/ By: Permit No.A
13125 SW Hall Blvd., Tigard, OR 97223
Plan Rzview'
Phone: 503.639.4171 Fax: 503.598.1960 ) Date/By: Other Permit No.:
Inspection Line: 503.639.4175
ia Date Ready/By: Juris ®See Page 2 for
Internet: www.tigard-or.gov Notitled,Method: Supplemental Information
-
TYPE OF WORK FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description Qtv. Ea. 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
❑ I- and 2-family dwelling ® Commercial/industrial SFR (2) bath 437.78
F-1 Accessory building ❑Mu1ti-family SFR (3) bath 500.32
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: 7105 SW Hampton Street Catch basin or area drain 18.76
Drywell, leach line, or trench drain 18.76
City/State/ZIP: Tigard, Oregon 97223
Footing drain (no. linear ft.: ['age 2
Suite/bldg./apt. no.: Project name: Kaiser Tigat•d Dental Manufactured home utilities 50.03
Cross streeUdirections to job site: 217 to SW 72"d Avenue, then cast on Manholes 18.76
Hampton Street. Building is second building on the north side. 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: Lot no.: Fixture or item:
Tax map/parcel no.: 2S101AC01300 Backtlow preventer 3127
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
Replace selected sinks and faucets. 4d" ,V-, 2 /C Cfi'Z+;~i Dishwasher 25.02
7t ZCf`~ir, 3 fr/n~/li Drinking fountain 25.02
C c t U' /✓T19~'/fwd `hL /v'E= Ejectors/sump 25.02
® PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: Kaiser Permanente Fixture/sewer cap 25.02
Floor drain/Floor sink/hub 25.02
Address: 500 NE Multnomah Sheet
Garbage disposal 25.02
City/State/ZIP: Portland Oregon 97232 Hose bib 25.02
Phone: (503)813-4681 Fax: ( ) Ice maker 12.51
® APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Crav Bear Construction Co. Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: John Witty
Roof drain (commercial) 12.51
Address: P.O. Box 4365 Sink/basin/lavatory 25.02
City/State/ZIP: Portland, Oregon 97208 Solar units (potable water) 62.54
Phone: (503) 515-3263 Fax:: ( ) Tub/shower/shower pan 12.51
E-mail: johWa gbccoregon.com Urinal 25.02
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: Grav Bear Construction Co' Water piping/DWV 56.29
Address: Same as above Other: 25.02
City/State/ZIP: Same as above Subtotal
Phone: (503) 282-2116 Fax: (503) 282-0349 Minimum permit fee: $72.50
Plan review (25% of permit fee)
CCB Lic.: 151 -7 33 Plumbing Lic. no.: S~ P State surcharge (12% of permit fee) j'-
Authorized signature: TOTAL PERMIT FEE c b%
Print name: John Witty Date: 10/21/09 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
'Fee methodology set by Tri-County Building Industry Service Board.
I.ABuildingVPermitsVPLMU-PermitAppdoc 10/01109 440-4016](10/02TONME13)
Hygiene Rooms Dentist Rooms Oral Surgery
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Tigard Dental Remodel