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Permit q CITY OF TIGARD MASTER PERMIT ?` COMMUNITY DEVELOPMENT Permit #: MST2010 -00081 lFr, Date Issued: 05/06/2010 , [ GhAU 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 V ,, ,, _ Parcel: 1S135DC04700 Jurisdiction: Tigard Site address: 9425 SW TANGELA CT Subdivision: TANGELA Lot: 2 Project: Brockway Project Description: Repair water damage- Sheet rock and insulation only for structural - no plans required - field inspection only MAV BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front. 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Total: sf Value: $23,607.00 Rear: 0 PLUMBING Sinks: 1 Water Closets: 2 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 0 Catch Basins: 0 Lavatories: 2 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 0 Tubs /Showers: 2 Garbage Disp: 1 Water Heaters: 0 Water Lines: 0 Drains: 0 Bckflw Prevntr. 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Furn <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Fum > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add! 500 sf: 0 20 1-400 amp: 0 201 -400 amp: 0 1st W/O Svc/Fdr: Limited Energy: 401 -600 amp: 0 401 -600 amp: 0 Ea addl Br Cir: 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: Owner: Contractor: Required Items and Reports (Conditions) BROCKWAY, STEPHEN H THE GROUT CO PO BOX 80155 PO BOX 2250 PORTLAND, OR 97280 PORTLAND, OR 97208 PHONE: PHONE: 503 - 222 -5654 FAX: Total Fees: $933.67 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in - • - - ith approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. A NTION: Oreg•• la. equires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 -00 -0010 through OAR 9' 001 -$ 100. ou may obtain a copy of the rules or direct questions to OUNC by calling 503.246 6699 or 1.800.332.2344. k _____ i , �' �- Issu d By: Permittee Signature: Building Permit Application r$�� pp Y's{ 7{'' XiN2o,lksi7 P.3 ;,, ." a 1 _ I : Residential x I UR of I ILI ` US D , ++l. Si.. 4 _ _:L ,S Y-..._ •.. '' cr. 7 ti -i' _t, 0 ! ' ' ' Received , ��/A1 - City of Tigard DateB : !"iN 5 � Permit a r _ ` , U PI 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review Ar • 17 ;. Phone: 503.639.4171 Fax: 503.598.1960 DateB Other Permit: �! �' n Inspection Line: 503.639.4175 Date ReadyBy: 1�ds: ® See Page 2 for . -- .. Internet: www.tigard- or.gov Noti fied /M ethod: b �� Supplemental Information . TYPE OF WORK . ' ' , REQUIRED DATA: 1- AND 2- FAMILY'DWELLING . ❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all ❑ Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the C ATEGORY OF CONSTRUCTION • • work indicated on this application. • Valuation: S 7 °d X I -and 2- family dwelling ❑ Commercial /industrial Gr>7 El Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: . J013 SITE 'INFORMATION AND LOCATION Total number of floors: Job site a d d r e s s : 6 xi Z 5 Ski rAJ . LA GT - New dwelling area: square feet City /State /ZIP: 7I /, d b� 1702.13 Garage /carport area: square feet Suite/bldg. /apt. no.: ` �� Project name: Covered porch area: square feet Cross street/directions to job site: T S LA 1 c, 7 ID C )p Deck area: square feet ( Fr Lf1i; CI 1; eth Other structure area: square feet REQUIRED DATA: COMMERCIAL-USE CHECKLIST Subdivision: Lot no.: Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. • /� � t'i y Valuation: $ NVl L 9kl4/V� �rA- 1K. - 1�JR FiAYi f S 1A741t71,1 4 f ini)'jH i I_Q.C, 15H PL vM� 1,J4, A C 47 Fv2� /41-F r Existing building area: square feet c-424 G4 L A>c.T M • / 5 New building area: square feet PROPERTY OWNE ' • - ❑ TENANT Number of stories: Name: yir f , lk k L1Lto A y Type of construction: Address: 9 7P Z 5_23 5 4, rig-4) ALA c.. Occupancy groups: City /State /ZIP: T-L t �A_ft_•p t ©J °V7 2..2_3 Existing: Phone: (5 3 3) 4 7 pt i Fax: ( ) New: ❑ APPLICANT • - ❑ CONTACT PERSON NOTICE • Business name: m c . U b 1) r co mf f 7 y/ All contractors and subcontractors are required to be Contact name: '?� �y U V licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: 1 l a 0 N Iv 4 £ jurisdiction in which work is being performed. If the City/State/ZIP: Q applicant is exempt from licensing, the following reasons y I e LT L.-/k-L) v, c apply: Phone: (90 ) a„ L . - 5(.., A 34...t 13 Fax:: (g 47,1 ' ot44.1 E -mail: G 2 6, P.-011 T a._ A' L.. C,OM CONTRACTOR ' ' • Business name: 4 AM f .- BUILDING PERMIT FEES* , . Address: • (Please refer to fee schedule) Structural plan review fee (or deposit): City /State /ZIP: Phone: ( ) Fax: ( ) FLS plan review fee (if applicable): CCB lic.: Total fees due upon application: 3 5�c I 9 3 . 47 /f /J Amount received: � Authorized signature: if I _ f�j� This permit application expires if a permit is not obtained �( within 180 days after it has been accepted as complete. Print name: ? e J }., /_ h p V ' r ' Date: y . 9 . l 0 * Fee methodology set by Tri- County Building Industry 'b Y / y ` Service Board. L\Building \Permits \BUP -RES PermitApp.doc 10/01/09 440- 4613T(1 I /02 /COM/WEB) n re ��, 4) //1l 17 ■ Building Permit Application Checklist One- and Two - Family Dwelling .. tr °1 OR .OI i [Tit E,, tisl ' O iM1 . \ ` - xn� �?- z��s r. ... mar f - -� -.-. , _, . . . a . ... . .. ,...� e ;' Received Cit of Tigard Date/By. Permit No.: a 13125 SW Hall Blvd., Tigard, OR 97223 :^ 11 Phone: 503.639.4171 Fax: 503.598.1960 Associated permits: IICAI&I} 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing ❑ Mechanical Internet: www.tigard- or.gov ❑ other: h[ FI FOLLOWINC. I EN1S i RL;IREQUIIZh DTOR UIEW; yes No .r, N/A.. 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑ 2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑ 3 Verification of approved plat/lot. ❑ ❑ ❑ 4 Fire district approval required. Name of district: ❑ ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑ 6 Sewer permit. ❑ ❑ ❑ 7 Water district approval. ❑ ❑ ❑ 8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑ 9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑ basin protection, etc. 10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if copyright violations exist. 11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ ❑ there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements and driveway; footprint of structure (including decks); location of wells /septic systems; utility locations; direction - indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and surface drainage. 12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑ and location. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑ furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc. 14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑ floor, wall construction, roof construction. More than one cross section may be required to clearly portray construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings and foundation, stairs, fireplace construction, thermal insulation, etc. 15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ ❑ Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope. Full -size sheet addendums showing foundation elevations with cross references are acceptable. 16 Wall bracing (prescriptive path) and /or lateral analysis plans. Must indicate details and locations; for non- ❑ ❑ ❑ prescriptive path analysis provide specifications and calculations to engineering standards. 17 Floor /roof framing. Provide plans for all floors /roof assemblies, indicating member sizing, spacing, and bearing ❑ ❑ ❑ locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑ systems, see item 22, "Engineer's calculations." 19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑ over 10 feet long and /or any beam/joist carrying a non - uniform load. 20 Manufactured floor /roof truss design details. ❑ ❑ ❑ 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas- piping schematic is required ❑ ❑ ❑ for four or more appliances. 22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or , ❑ ❑ ❑ architect licensed in Ore Ion and shall be shown to be a Ilicable to the •ro under review. JURIS_DIC 1 LONA I'I:CII ICS 23 Three (3) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". ' ❑ ❑ ❑ 24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ ❑ ❑ 25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑ 26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ ❑ \27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑ 28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑ and protection measures must be drawn to scale and must include the project arborist's signature of approval. 30 A Clean Water Services' Sensitive Area Pre- Screening Site Assessment form is required for all building additions, ❑ ❑ ❑ including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings on a lot of record approved prior to September 9, 1995. 1. \ Building \Permits\BUP- RES- PermitApp.doc 03/21/06 440- 4613T(I I /02 /COM/WEB) May 05 10 11:35a Larry Marson 503 - 296 -4094 p.l 05/05/2810 08:119 5035561960 liiY OF 3iuARD PAGE 01101 F,te_ctrical Pe1mit Application C,V 1 City , fT,d 5 � ,.�1.. puss Nall Blvd_ Tigard. OR 97223 nvv Atnw . Na: Phone: 03.639.4171 Fax 503.598.1960 � P\ : i 1 PA 1 ; _ inIpccri, , Line: 503.639.4575 ^r�` �j wL: Other Permit Internet www.figerd or. gnv CO f (I rr. , hoer Q 9�e Pose 7 For iri St laferaatlaw O New construction ddition/alteration/ ' a -'fi s trlction ❑ cheek cd ❑ Demolition Reeve Ileac all IOW *ply (subunit j eels orplm„ nlecra, ah�tc 6cto. `.; :... f... , ❑ Other: °Service err Redd doo =pa m• anon ): _ ..f�, where the *nibble (mhrumor ° Marho +R over tl n a m,;ij. - .- 1- g . , W `R •. - . - • e■etede 10,000 ❑ Merino erect . Ws �. •, amps a 150 vglb a 6 eld 2 -6mily , ling D Commercial/industrial .. . an te Merino b"d�118'• ❑Multi- ftsiiily ❑ Master builder 0 mawfor,n Q boddir ��1lae ntek+daaat l Otlltr. ()sire prep. C/ rnlreny or 71 K vA or lob no.! I lob site address: — ❑r loom QereepE•. °l- 2 ° °t.4 t11fP a mn,e, 0C°rP>kY• City/State/VP; t 0Sit, or owe meekte mats. 0 Reerrafioeal mks v 1104 17z2- 3 0 nuard„s recision. ❑ S"prlY 'rol b ryc for amore !hers Project 11a=roe: ❑ Stroke err order600 600 wilt Kornai. 58 %2i/directions t. or job site: - . New mildews, click or maid-fa ` Subdivision: includes 000s eludes araneYea f dwelling unit. MEM 1.q. R or few Tax nlaprperce no.: _ !68.54 Et Limited t vu sq. R. de vial n 1111.3311111.1.1 •e � R ,.. ' Limited 2 • 1 if r • r manna' s l a�p0 a 67 2 Services or fecden ianalatie M e ndes and/or rdncatian . .''. 1 a 200 amps or icni M t . : : . • 1 � . ' R[ X i m 400 a npr 10030 ®11.1111. 2 E _ 14_, 4 ot antler 600 amps MO 34 2 • Address: F- anpl to 1.000 amps 301.04 - 2 City/State/71P " - - Over 1,000 amps or nits r 552.26 2 T ( -i _ ` wporary anwlem er feeders irsbnagoa. aiterahon, arld/er Pbooe: ( . L7 78e t Fac ( ) 2200 mn or vex ` 19.36 t _ Owner instaUatiaa: TV installation is being made on property that I own which is out 201 amps m 400 omlps - intended for Sala lease, r,• t. or exchange according to ORS 447, 449 670, and 701. ao1 to 999 amps ;23.08 2 Owner signature: tin, 2 C11.-' d� Date. A Fee h r breach _. w, with � . er eilrao, r pastel ' :.. C1` , .:12 . 02Witt attive ruvitear Ce f Rosiness name: 'r1: -/ ,, , eKh 6ralyd cireuir 7.42 2 V/ t f � .e {! C42 R. Fee for handl circuit, *rennin Contact name' 'z� t , service err feeder kg Fuse ril s L bran either 18 2 Address: 1 ` . ,, = Each add I mulch chain L i _ 2 City/$tard7_IP' invite or feeder act included _ : . mu a or mf er �� Phone: (e ) dwdwelling. savior and/or feeder 2 E -mail c r t e Fez: ) Recount oa y r 67. ea ` 2 Pump or'n1800an cirdc 6784 2 - Signor outline tit;horlp 67.84 2 Business name: Sit;ae eilait(sy or Nlahod a i. ,, e •_u. elterativn or meter am. p� Address: Each addition' Inspection 2 • . S 5 7 a iasfaecaioe evrr atlaarabk in / any hr of the a0ov City/5taoe/Z{P: , r t Ad n () lir len - 66.25/ hr - 7 .t •� ) 66.25/hr Phone: (�3) v 11 trlialtltmt(1 Er min) 76 rsrhr \ CCB Lie.: / , I Electrical lac.: , _ i ey �t, t ared {Y. In 1 w I so' DO/ lo i Sleprv. Electrician signature feglluedi i `� � ; Y:i < :, - Print name: ` Plan review (25%ene ma lee)• b- t�v� b late : . - �` .0 , stoic surcharge (12% of permit foe): ` Authorized signaturc 1 tares ` roiwt PERMIT Fri: "'. �t = - lob wait Bonnina end,. ii alt a yawn 1a ow'Wi nce Iddda lei Print 118111C: - 1 DM: days alter a Me bate .as�,r. r t emartrm. • Newbet or iteireeliaar alboed per remit. eoixwairorooarc :abe.10.4,4o, 1 • • Lev ttAF1.�Tt11ANCOMAViA • 1 May 05 2010 1 2 : ADVANCED HEATING 5037744391 p.l 05/05/2010 08:21 50359/31950 CITY T IGARD ___ .. _. — _ - PAC,£ 81/01 .. -4x•4 "',r � iy1 *,� � � ' IC ' . �� P iwrtc: 5113.6300171 oor A � ( � atl�rsnn. t I e �j � i l ;; m ction Lim 503.639. cr w,w.tigard- or -gov at ®� NO k- r - ^"71" Mrtitat Permit s ere bd n the valu of he aatic • perPorp(tcedttd. ladleate tea the vatao ( to dtc tleata dollar) ( oatl Q Addition/alteration /replacement }atwr o overh ead and ►� New construction meehtniesl mata+ai e • t QDem Demolition pOtitef: o • Cptg6'O*1 ",0 P Accessory building: Total D t • and 2•fntnity dwelling Q Commercial /industrial 0 •� �;� Mosta builder 0 Other: � °" 0 Multifamily -Ed►T rr . Vt. STT 1l�FREllllf ' ' Ai teonditionb , OVEINIIIIM Job site addrms: ' 4 v Furnace to 0D6 BTU 41011M14 City /Statc/Z[P: 6,..g.1.-- b / ' Fumeco 100 000+ BTU ductolveft ION 6 MIN p�gCet Mae: 11111111,10111111 Suittlbtdg.l. nu.: k liell 23,32 Residential boiler (radiator or _rgin Is Unit t►�� (�'tY� pot electric), �� in,waii in su" cndnd etc. Lot tw.: Other: 5 Other t i ,' maces 1.11EM� �': t 33 sin t r r VC P - " - v. "4 nil� Wood dm. ace/Insert rffE2TT3��.32� Chiang ninorMn r> ctvent D 111101E r Name: • L Envirosmenta 4 bust and ventilation rev Add: ,L _ r y = 33 MIN 33.39 r _�: S dud exhaust(batheamm, mum Male: ( ) Fax: ( ) toilet • attmettts• aril • rooms : CIAPPlE.dger •' :la .COMALT MOM Attic/ - -.ace tam _ 23.32 Other: ME 23.32 Business name: v .- Lit C , Fu - ,;). Cavan Dame: ( e �, ; Av 4 - k, p el 514.15 for first her 03 for lads odetional Address: _ City/State/VP: Watl/sus • coded/unit heater _ Fiore: (kli ) _ (i ; Fax:: (So ) - Water beater __ IIIII t'! wl• EnTilii Address. .u i s) ;zip other: �M City /SIM/UP: O� lUO '' 9 7Aoba P,ironc: ( �G) 7 l Fox: ( _ ) _ _ Mi • .. It Gee , pp CCB tic.: • qt S 7 di 31ate made Authorized si:' s o a �sr TOlALJ'EftMIT . . `/� � ' Ala T�• fanntt aOyCaetlx •xoi► d a gv+mti • not oblne .nadx AAP Print CUM: r • dy a aAer i• tw boa teeeprsd �. de tr. d ...I AO • !- tilt � 'Ji Date: -( al , • teexetbodo10 ,s bx pTri- Ca nu.lrySulldiegIla/v PlauiViogtPar Om FpoThhAPP,dos I0f img txry Se(vfco80sad May 05 10 12:08p p 05/05/2010 08:22 5035981960 CITY CF TIGARD PAGE 01/01 Plumbing_Permit Apvlicatioa Building Fixtures ., - „ iii ui I it l i .1, r) \ l 1 ' _ city or Tigard V 5 2 1, eccrved _ a (3125 SW Hail Blvd , Tigard. OR 92223 on `' ` �.1 Down ' T • Phone: 503.639.4171 FDA 50 1960 G. ' n " "" ^- ^ W. t i.� . B . Other Pe rn t Nn.. Inspection Line' 503.639 4 t 75 Cl QV T` ' .1 ! , d - et x for i _).,,:., , rani FA Pa Internet www tigsrd-or.gov 1Ne'3D otlfed /en o,„d Supplemental intarmaaon 0 New construction 0 Demolition , F'Ot ¢eial in nrmarion use checklist bcacription I. Qty 1 F.a 1 T01111 0 Addition /alteration /replacement 0 Other: New 1- 2- family dwellings (includes 100 ft. for each utili connection CATEG ' ! SFR (1) bath 312.70 0 1- and 2- family dwelling 0 Commercial /industrial SFR R) baUt 437.78 Acenss building SFR (3) hash 500.32 [] 0 TY g ❑ Multi-family Each additional bath/kitchen 25 02 0 Master builder L 0 Other: 2 ` Fue s prinkles (� sq fl) Page .. JCi6.31'C*.• i!97O it A ',{ON 0 CoCit'ti'i'n • • { Site utilities: • Catch basin or area drain 18.76 Job site address: _ 4 '7 . y1 r4A h -- ) � - �"� r ! Drywcll, tench tine, nr nrnct, drain 14.76 Y ie , 4 , 2 1 ate) Footing drain (no. linen ft. • __ --) Page 2 Suite/bldg. /apt. no.: Project name: Manufactured home utilities 50.03 Cross street/directions to job site; 1 , -}, Manholes 18.76 —1 � ` k Rain drain connector 1 R,7G Sanitary sewer (no. linear ft. .... ) Pogc 2 f Storm sewer MO. linear ft.. Page 2 Ware sc.-vice (no, linear ft. ) Pow 2 2 Subdivision. Lot no., Ftatute or item: Tox mop /parcel no.: _ Baekflow prcvcnter - 31.27 t , . Ic :•• Backwater valve 12.51 - Clothes washer I 1 25 02 .a r !` • .. - F1 X lli-t I Dishwasher / { 25 02 1 Drinking fountain f 25 07 L- iectors/surnp 25 02 . • 1 _. -.- • [ 1 OWNFItk`.• • , . . f .r.` : pir' mow ... Expention tank 12 51 Name: y �� 2..�w��/ Picture /sewer cop 25.02 Nam - Floor drain /floor sinlowt 25.02 Address: °I 4 L- 5 s r 6_ SL - 't W v� Garba disposa 25.02 City /State/71P: i4it • d b 4) 7 2«t 3 Hose bib 25 02 Phone (504 ) kr, 7 - y 1421 Fax: ( 1 Ice rnekcr 12.51 a t.,i; n .c :r'ik' r } lrtcrceptnr /green trsp 25 02 Medical gas (value: S _� Page 2 Business Milne; 1tf_ r C- 1 - Primer 12 51 Content name: // -!'] A ,Z1,t -- - - J � Roof chain (commetciai) 12 51 Address' �y 1t _ Sink/basin/lavatory 1 25 02 City /State /ZIP � �•- ' _ rc-�C `� r4r f f f 3� t f Soar uniu (potable water) 62.54 Phone: (• ) � Fax:: (pp} ) oZ 74 1 Tub /shower/aho pan 12.51 E•ma;l• G aLt.�.R Ou7- � /�� Lc .•st� Urinal a 25.02 Water eloRa at 25.02 Water heater 37 52 Business rime: L. 7, y / P Li t / 4-. Water piping/DIN y 56 29 ' Address: �� fj f �j 'r L f Other _z5.oz City /State /Z.iP: ' el • L • 0 20Cer I Ph Subtotal oney a 41 Q Minimum fee: S72.S0 ~ u ( yd } }._�.`1 K -vZ9t7 ' •Fax (��) �? 7S - . _,_.____ CCB Lie.: - 1 i. ! C ,, Plumbing, tic. no . . (, a„ , Jy Plan review (25%ofpermit fee) �_'�__ I State atttthatgt (I2 °( of perm rte) Authorized signature: ;`- I . _ - TOTAL PRRntiT FEE 11 Pp permit a lrceti"n ea Iran If , erm• i n pla riot ob ed within tan day, I Print n�me�'� f-�=�5 Datr.6----6.....46 n after it h"r Neu aKepltu o• complete. "Fee meabadc4opy eel by Tri -Canary Mottling )ndn'ny Sconce Bolo! r.\ 9tritdinrPermitett •Urns- ra.monee doe !Mom” .40.n610T( I anLCn•/Wbe)