Permit •_., CITY OF TIGARD MASTER PERMIT
PERMIT #: MST2001 -00035
�I�j DEV W H Hall Tigard, R SERVICES ) 639 -4171 DATE ISSUED: 2/2/01
SITE ADDRESS: 11490 SW 121ST AVE PARCEL: 1S134CA-01200
SUBDIVISION: BURLWOOD ZONING: R -4.5
BLOCK: LOT: 005 JURISDICTION: TIG
REMARKS: Fire damage repair.replace (8) 2ft rafter tails and (8)6ft rafter tails and replacing (1)4x12 - 18 ft long
porch beam and one 4x4 post and all bath room fixture no plans require
BUILDING
REISSUE: STORIES: FLOOR AREAS REQUIRED SETBACKS REQUIRED
CLASS OF WORK: REP HEIGHT: FIRST: sf BASEMENT: sf LEFT: SMOKE DETECTORS:
TYPE OF USE: SF FLOOR LOAD: SECOND: sf GARAGE: sf FRONT: PARKING SPACES :
TYPE OF CONST: 5N DWELLING UNITS: FINBSMENT: sf RIGHT:
VALUE: $ 18,000.00
OCCUPANCY GRP: R3 BDRM: BATH: TOTAL: 0.00 sf REAR:
PLUMBING
SINKS: WATER CLOSETS: 1 WASHING MACH: LAUNDRY TRAYS: RAIN DRAIN: TRAPS:
LAVATORIES: 1 DISHWASHERS: FLOOR DRAINS: SEWER LINES: SF RAIN DRAINS: 1 CATCH BASINS:
TUB /SHOWERS: 1 GARBAGE DISP: WATER HEATERS: WATER LINES: BCKFLW PREVNTR: GREASE TRAPS:
OTHER FIXTURES:
MECHANICAL
FUEL TYPES FURN < 100K: BOIL/CMP < 3HP: VENT FANS: CLOTHES DRYER:
FURN > =100K: UNIT HEATERS: HOODS: OTHER UNITS:
MAX INP: btu FLOOR FURNANCES: VENTS: WOODSTOVES: GAS OUTLETS:
ELECTRICAL
RESIDENTIAL UNIT SERVICE FEEDER TEMP SRVC /FEEDERS BRANCH CIRCUITS MISCELLANEOUS ADD'L INSPECTIONS
1000 SF OR LESS: 0 - 200 amp: 0 - 200 amp: W /SVC OR FOR: 1 PUMP /IRRIGATION: PER INSPECTION:
EA ADD'L 500SF: 201 - 400 amp: 201 - 400 amp: 1st W/0 SVC /FDR: SIGN /OUT LIN LT: PER HOUR:
LIMITED ENERGY: 401 - 600 amp: 401 - 600 amp: EA ADDL BR CIR: SIGNAL/PANEL: IN PLANT:
MANU HM /SVC /FDR: 601 - 1000 amp: 601 +amps 1000v: MINOR LABEL:
1000+ amp /volt :
PLAN REVIEW SECTION
Reconnect only:
> =4 RES UNITS: SVC /FDR> =225 A.: > 600 V NOMINAL: CLS AREA/SPC OCC:
ELECTRICAL - RESTRICTED ENERGY
A. SF RESIDENTIAL B. COMMERCIAL
AUDIO & STEREO: VACUUM SYSTEM: AUDIO & STEREO: FIRE ALARM: INTERCOM /PAGING: OUTDOOR LNDSC LT:
BURGLAR ALARM: OTH: BOILER: HVAC: LANDSCAPE/IRRIG: PROTECTIVE SIGNL:
GARAGE OPENER: CLOCK: INSTRUMENTATION: MEDICAL: OTHR:
HVAC: DATA/TELE COMM: NURSE CALLS: TOTAL # SYSTEMS:
Owner Contractor: TOTAL FEES: $ 468.77
MILLER, LYMAN L LAYS CONSTRUCTION CO This permit is subject to the regulations contained in the
MILL Tigard Municipal Code, State of OR. Specialty Codes and
11490 E SW 121ST AVE 7400 CONSTRUCTION NSTR U TI
TIGARD, OR 97223 PORTLAND, OR 97266 all other applicable laws. All work will done i
accordance with approved p ed plans. This perm it will expire if
work is not started within 180 days of issuance, or if the
work is suspended for more than 180 days. ATTENTION:
Phone: Phone: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set
Reg #: LIC 4017 forth in OAR 952 - 001 -0010 through 952 - 001 -0080. You
may obtain copies of these rules or direct questions to
OUNC by calling (503) 246 -1987.
REQUIRED INSPECTIONS
Framing lnsp
Special insp. required - r
' 1 h ,_6 -/ . , _ _ " � a h2 t �Z •
Rain drain Insp � J
Plumb Final
Final inspection
Issued B C (/.(. Pe rmittee Signature ::i, /.Lu4�� ���` - _
Call (503) 639 -4175 by 7:00 p.m. for an inspection needed the n -xt business day
._.Q- r / 9 ,1711 e r
. .
,.
.. .
.. Building P
�. `,t,.;lyi City of Tigait,. ived. 7� %/ Permit no.: 4fSr�O %OD03
Project/appl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard, OR 97223
Phone: (503) 639 -4171 Date issued: By: 'Receipt no.:
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: 1 &2 family: Simple Complex:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family ❑ New construction ❑ Demolition
❑ Addition/alteration/replacement ❑ Tenant improvement ❑ Fire sprinkler /alarm l,.Other: cif—L.? (L ' ca ^—
JOB SITE INFORMATION
Job address: 1 14-1 ' 0 Sw I 2_1 5 t- Bldg. no.: Suite no.:
Lot: I Block: (Subdivision: I Tax map /tax lot/account no.:
Project name: j , 2 : 2 _ 7 p - - c : N i 'I i u ( 2 . 0 ci i o i L S a 4 b - i - 5 -f I 4 ' ert i L . 5/ lee: r ; (-'
Description and location of work on p r special conditions IZ P)A C r fi ' i2 ) t 4 74/ . 1S S i S h' 414 ',..,�
I 4 I.( )c ■ s 0 k--,-' A 4 t' J t g 1 _ s' , S "`4tit i c: b ^- H .' P r rtd 'v , —
OWW'NER FOR SPECIAL INFORMATION, USE CHECKLIST
Name: L .1 m aJ rn, )1 (Floodplain, septic capacit }',solar, etc.)
Mailing address: i t l g 0 SL.S i L/ ! 11 J i 1& 2 family dwelling:
City: -- y ,c, 0_, I State: 0 ILI ZIP: 'j 7 ZZ 3 Valuation of work $ l 66 UC.)
Phone: r2‘) 9 26:, °l I Fax: I E -mail: No. of bedrooms/baths > i
Owner's representative: /4r rJ C; (, S I ✓ Total number of floors
Phone: 2. -3 c G Fax: 2 --; , r . - E -mail: New dwelling area (sq. ft.)
APPLICANT Garage /carport area (sq. ft.)
Name: <' , — ( AL, 1 t,,,s 14R1 y 5 (0 ,,,pc / n,,, ,L7u;- Covered porch area (sq. ft.)
Mailing address: 7Y 00 S& ,,. / L t,,,.ra LA C A 1/ Deck area (sq. ft.)
City: i' o&L * - 1,ar-J I State fj r? ZIP: `j 7 z d Z Other structure area (sq. ft.)
Phone: So • z 3 i Wit' Fax:5c; -; 2.3 3 E -mail: c ;1' . ( yi 4w Commerciallindustriallmulti-family:
CONTRACTOR Valuation of work $
Existing bldg. area (sq. ft.
Business name: L A `'(S (IIN` 7;2,,Ac.. i t C J New bldg. area (sq. ft.)
Address: - 71-1 t) U Sc rrj , L ,..rail , : tl %./4.,-) ^ ,� Number of stories
City: I rL`i1 ate/ I State:04-I ZIP: C
Type of construction .
Phone: ,> 2 u y4Fax:5 2_,7 E -mail:
"" Occupancy group(S : Existing.
''
CCB no.: D ) New:
City/metro lie, no.: Notice: All contractors and subcontractors are required to be
ARCHITECT /DESIGNER licensed with the Oregon Construction Contractors Board under
Name: provisions of ORS 701 and may be required to be licensed in the
Address: jurisdiction where work is being performed. If the applicant is
City: I State: ZIP: exempt from licensing, the following reason applies:
Contact person: Plan no.:
Phone: Fax: E -mail:
ENGINEER
Name: Contact person: Fees due upon application $
Address: Date received:
City: IState: IZIP: Amount received $
Phone: I Fax: I E -mail: Please refer to fee schedule.
I hereby certify I have read and examined this application and the Not all jurisdictions accept credit cards, please call jurisdiction for more information.
attached checklist. All provisions of laws and ordinances governing this ❑ Visa ❑ MasterCard
work will be complied with, -w th • t d erern or not. Credit card number: / /
<_ r Expires
Authorized signatu> (/ tdilri � c ' Date: l/ 3i) al Name of cardholder as shown on credit card
Print name: `i: (l f? -r jm - Cr �\ - ,\ Cardholder signature $ Amount
Notice: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. 440 -4613 (6roOICOM)
One- and Two - Family Dwelling
•
fie , , Building Permit Application Checklist Reference no.:
Associated permits:
City of Tigard City of Tigard
`J b ❑ Electrical ❑ Plumbing ❑ Mechanical
Address: 13125 SW Hall Blvd, Tigard, OR 97223 ❑ Other:
Phone: (503) 639 -4171
Fax: (503) 598 -1960
TILE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes No 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.
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 s'pt+s -df 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 Oregon and shall be shown to be applicable to the project under review.
JURISDICTIONAL SPECIFICS
23 Five (5) 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 & 22 above.
25 Building plans shall not contain red lines or tape -ons.
26 No rolled, reversed or mirrored building plans will be accepted.
27
28 •
Checklist must be completed before plan review start date. Minor changes or notes on submitted plans may be in blue or black ink.
Red ink is reserved for department use only. 440 -46/4 (M0/COM)
Mechanical Permit Application
Date received: 7 /oi / Permit no.: A/S7 f 49035
" City of Ti and
g Projecdappl. no.: Expire date:
City of Tigard Address: 13125 SW Hall Blvd, Tigard OR 97223 Date issued: By: Receipt no.:
Phone: (503) 639 -4171
Fax: (503) 598 -1960 Case file no.: Payment type:
Land use approval: Building permit no.:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family O Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Other:
JOB SITE INFORMATION COMMERCIAL VALUATION SCHEDULE
Job address: Indicate equipment quantities in boxes below. Indicate the dollar
Bldg. no.: I Suite no.: value of all mechanical materials, equipment, labor, overhead,
Tax map /tax lot/account no.: profit. Value $ .
Lot: ( Block: I Subdivision: *See checklist for important application information and
Project name: jurisdiction's fee schedule for residential permit fee.
City/county: I ZIP: 1 & 2 FAMILY DWELLING PERMIT FEE SCHEDULE
Description and location of work on premises: AND COMMERICAL/INDUSTRIAL EQUIPMENT SCHEDULE
Fee (ea.) Total
Est. date of completion /inspection: Description Qty. Res. only Res. only
Tenant improvement or change of use: HVAC:
Is existing space heated or conditioned? ❑ Yes ❑ No Air handling unit CFM
space insulated? ❑ Yes ❑ No Alt rati conditioning ti ng planrequired)
Is existing P Alterati of existi HVAC system
MECHANICAL CONTRACTOR Boiler /compressors
,. Business name: ,' D j ).h�(� .S tr r ! State boiler permit no.:
HP Tons BTU /H
Address: ZZ I ' 5p e t11 Fire/smoke dampers/duct smoke detectors
City: ?a N., c 1 I State.()2 I ZIP: t) 20'2_ Heat pump (site plan required)
3_ ay 1 I Fax: 2.36 FpL/ E -mail: Install/replace furnace/burner BTU /H
Phone: Z 3" Including ductwork/vent liner 0 Yes ❑ No
CCB no.: Install/replace/relocate heaters — suspended,
City /metro lic. no.: wall, or floor mounted
Name (please print): Vent for appliance other than furnace
CONTACT PERSON Refrigeration:
Absorption units BTU/H
Name: Chillers HP
Compressors HP
Address:
Environmental exhaust and ventilation:
City: I State: I ZIP: Appliance vent
Phone: Fax: E -mail: Dryer exhaust
OWNER Hoods, Type V IUres. kitchen/hazmat
hood fire suppression system
Name: Exhaust fan with single duct (bath fans)
Mailing address: Exhaust system apart from heating or AC
City: I State: I ZIP: Fuel piping and distribution (up to 4 outlets)
Type: LPG NG Oil
Phone: Fax: E -mail: Fuel piping each additional over 4 outlets
Process piping (schematic required)
Name: Number of outlets
Other listed appliance or equipment:
Address: Decorative fireplace
City: I State: I ZIP: Insert — type
Phone: I Fax: . .._, E-mail: Woodstove/pelletstove
w/ Other:
,/ Applicant's signature: )L- 6.46 I Date: ■ 13D Jo I " Other:
Name (print): e� (', f }<►,u s
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Permit fee $
❑ Visa ❑ MasterCard Notice: This permit application Minimum fee $
Credit card number: / expires if a permit is not obtained Plan review (at _ %) $
Expires within 180 days after it has been State surcharge (8 %) .... $
Name of cardholder as shown on credit card accepted as complete.
$ TOTAL $
Cardholder signature Amount
440 -4617 (fvW/COM)
MECHANICAL PERMIT FEES •
COMMERCIAL FEE SCHEDULE: 1 & 2 FAMILY DWELLING FEE SCHEDULE:
TOTAL VALUATION: FEE: Description: Price Total
Table 1A Mechanical Code Qty (Ea) Amt
$1.00 to $5,000.00 Minimum fee $72.50 . 1) Furnace to 100,000 BTU
$5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and including ducts & vents 14.00
$1.52 for each additional $100.00 or 2) Furnace 100,000 BTU+
fraction thereof, to and including
$10,000.00. including ducts & vents 17.40
$10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and 3) Floor Furnace
$1.54 for each additional $100.00 or including vent 14.00
fraction thereof, to and including 4) Suspended heater, wall heater
$25,000.00. or floor mounted heater 14.00
$25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and 5) Vent not included in appliance permit
$1.45 for each additional $100.00 or 6.80
fraction thereof, to and including 6) Repair units
$50,000.00. 12.15
$50,001.00 and up $742.00 for the first $50,000.00 and Check all that apply: Boiler Heat Air
$1.20 for each additional $100.00 or For items 7 -11, see or Pump Cond
fraction thereof. footnotes below. Comp **
7) <3HP;absorb unit
to 100K BTU 14.00
ASSUMED VALUATIONS PER APPLIANCE: 8) 3 -15 HP; absorb
Value Total unit 100k to 500k BTU 25.60
Description: Qty (Ea) Amount 9) 15 -30 HP; absorb
Furnace to 100,000 BTU, including 955 unit .5 -1 mil BTU 35.00
ducts & vents 10) 30 -50 HP; absorb
Furnace > 100,000 BTU including 1,170 unit 1 -1.75 mil BTU 52.20
ducts & vents 11) >50HP: absorb
Floor furnace including vent 955 unit >1.75 mil BTU 87.20
Suspended heater, wall heater or 955 12) Air handling unit to 10,000 CFM
floor mounted heater 10.00
Vent not included in applicance 445 13) Air handling unit 10,000 CFM+
permit 17.20
Repair units 805 14) Non - portable evaporate cooler
< 3 hp; absorb. unit, 955 10.00
to 100k BTU 15) Vent fan connected to a single duct
3-15 hp; absorb. unit, 1,700 6.80
101k to 500k BTU 16) Ventilation system not included in
15 -30 hp; absorb. unit, 501k to 1 2,310 appliance permit 10.00
mil. BTU 17) Hood served by mechanical exhaust
30 -50 hp; absorb. unit, 3,400 10.00
1 -1.75 mil. BTU 18) Domestic incinerators
>50 hp; absorb. unit, 5,725 17.40
>1.75 mil. BTU 19) Commercial or industrial type incinerator
Air handling unit to 10,000 cfm 656 69.95
Air handling unit >10,000 cfm 1,170 20) Other units, including wood stoves
Non - portable evaporate cooler 656 10.00
Vent fan connected to a single duct 446 21) Gas piping one to four outlets
Vent system not included in 656 5.40
appliance permit '
22) More than 4 -per outlet (each)
Hood served by mechanical exhaust 656 1.00
Domestic incinerator 1,170 Minimum Permit Fee $72.50 SUBTOTAL: $
Commercial or industrial incinerator 4,590
Other unit, including wood stoves, 656 8% State Surcharge $
inserts, etc.
Gas piping 1-4 outlets 360 25% Plan Review Fee (of subtotal) $
Each additional outlet 63 Required for ALL commercial permits only
TOTAL COMMERCIAL $ TOTAL RESIDENTIAL PERMIT FEE: $
VALUATION:
Other Inspections and Fees:
1. Inspections outside of normal business hours (minimum charge -two hours)
$72.50 per hour.
2. Inspections for which no fee is specifically indicated (minimum charge -half hour)
$72.50 per hour
3. Additional plan review required by changes, additions or revisions to plans (minimum
charge- one -half hour) $72.50 per hour
* State Contractor Boiler Certification required for units >200k BTU.
** Residential A/C requires site plan showing placement of unit.
is \dsts \forms\rnech- fees.doc 10/11/00
.. . . Plumbing Permit Application
Date received: i /30/ Permit no.://$ - e00-35
.,, City of Tigard
° ' Sewer permit no.: Building permit no.:
,` --" Address: 13125 SW Hall Blvd, Tigard, OR 97223
City of Tigard Phone: (503) 639 -4171 Project/appl. no.: Expire date:
Fax: (503) 598 -1960 Date issued: By: I Receipt no.:
Land use approval: Case file no.: Payment type:
TYPE OF PERMIT
❑ 1 & 2 family dwelling or accessory ❑ Commercial/industrial ❑ Multi - family 0 Tenant improvement
❑ New construction ❑ Addition/alteration/replacement ❑ Food service ❑ Other:
JOB SITE INFORMATION FEE SCIIEDULE (for special information use checklist)
Job address: Description Qty. Fee(ea.) Total
Bldg. no.: Suite no.: New 1- and 2- family dwellings only:
Tax ma /tax lot/account no.: (includes 100 ft. for each utility connection)
p SFR (1) bath
Lot: ',Block: I Subdivision: SFR (2) bath
Project name: SFR (3) bath
City /county: I ZIP: Each additional bath/kitchen
Description and location of work on premises: Site utilities:
Catch basin/area drain
Est. date of completion/inspection: Drywells / leach line /trench drain
PLUMBING CONTRACTOR Footing drain (no. lin. ft.)
Manufactured home utilities
Business name: 1 ')'') 1- P t,► .'Yr b i N Manholes
Address: - 0 BD -' ''3 3 Rain drain connector
City: C ( .fa c 16 rir.e0 S I State:C :1_ I ZIP: t 7O t S Sanitary sewer (no. lin. ft.)
Phone:66 S ''J /6„ ) I Fax: • I E -mail: _Storm sewer (no. lin. ft.)
CCB no.: I Plumb. bus. reg. no: Water service (no. lib. ft.)
j\
Fixture or item:
City/metro lic. no.:
A Contractor's representative signature- - i 4 — Absorption valve
Back flow preventer
Print name: _,, " , .. 4 Date: i 3 • a Backwater valve
('ONTACT PERSON Basins/lavatory
Name: Clothes washer
Dishwasher
Address: Drinking fountain(s)
City: I State: I ZIP: Ejectors/sump
Phone: Fax: E -mail: Expansion tank
Fixture/sewer cap
Name (print):
Floor drains/floor sinks/hub
address: Garbage disposal
Mailing Hose bibb
City: I State: I ZIP: Ice maker
Phone: I Fax: I E -mail: Interceptor /grease trap
Owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the maintenance and repair made by my regular Roof drain (commercial)
employee on the property I own as per ORS Chapter 447. Sink(s), basin(s), lays(s)
Owner's signature: Date: Sump
ENGINEER Tubs/shower /shower pan
Urinal
Name: Water closet
Address: Water heater
City: I State: I ZIP: Other:
Phone: I Fax: I E -mail: Total
Not all jurisdictions accept credit cards, please call jurisdiction for more information. Notice: This permit application Minimum fee $
❑ Visa U MasterCard expires if a permit is not obtained Plan review (at %) $
Credit card number: / / State surcharge (8 %) .... $
Expires within 180 da after it has been
p TOTAL $
Name of cardholder as shown on credit card accepted as complete.
$
Cardholder signature Amount 4444616 (6/00/COM)
■
PLUMBING PERMIT FEES:
•
PRICE TOTAL New 1 and 2- family dwellings only:
FIXTURES (individual) QTY (ea) AMOUNT (includes all plumbing fixtures in PRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (ea) AMOUNT
Lavatory 16.60 for each utility connection)
One (1) bath $249.20
Tub or Tub /Shower Comb. 16.60 Two (2) bath $350.00
Shower Only 16.60 Three (3) bath $399.00
Water Closet 16.60 SUBTOTAL
Urinal 16.60 8% STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25% OF SUBTOTAL
Garbage Disposal 16.60 TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain /Floor Sink 2" 16.60 PLEASE COMPLETE:
3" 16.60
4" 16.60
Water Heater 0 conversion 0 like kind 16.60 Quantity by Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Capped
MFG Home New Water Service 46.40 Sink
MFG Home New San /Storm Sewer 46.40 Lavatory
•
Tub or Tub /Shower
Hose Bibs 16.60 Combination
Roof Drains 16.60 Shower Only
Drinking Fountain 16.60 Water Closet
Urinal
Other Fixtures (Specify) 16.60 Dishwasher
Garbage Disposal
Laundry Room Tray
Washing Machine
Floor Drain /Sink: 2"
Sewer - 1st 100' 55.00 3^
Sewer - each additional 100' 46.40 4"
Water Service - 1st 100' 55.00 Water Heater
Other Fixtures
Water Service - each additional 200' 46.40 (Specify)
Storm & Rain Drain - 1st 100' 55.00
Storm & Rain Drain - each additional 100' 46.40
Commercial Back Flow Prevention Device 46.40
Residential Backflow Prevention Device* 27.55
Catch Basin 16.60
Inspection of Existing Plumbing or Specially 72.50
Requested Inspections per/hr COMMENTS REGARDING ABOVE:
Rain Drain single family dwelling 65.25
Grease Traps 16.60
QUANTITY TOTAL
Isometric or riser diagram is required if
Quantity Total is > 9
*SUBTOTAL
8% STATE SURCHARGE
* *PLAN REVIEW 25% OF SUBTOTAL
Required only if fixture qty. total is > 9
TOTAL $
* Minimum permit fee is $72.50 + 8% state surcharge, except Residential Backflow
Prevention Device, which is $36.25 + 8% state surcharge.
* * All New Commercial Buildings require plans with isometric or riser diagram and
plan review.
is \dsts \forms\plm- fees.doc 10/10/00