Permit .. ' -CITY OF T I GARD
DEVELOPMEN SERVICES I'4' _ _''r "'`''
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CITY'dF TIGARD Plumbing Application Recd By i i
13125 SW HALL BLVD. Commercial and Residential Date Recd/ '
TIGARD, OR 97223 Date to P.E.
(503) 639 -4171 Date to D r
Permit s oken- a 20
Print or Type Related SWR li
Incomplete or illegible applications will not be accepted Called
Name of DevelopmentlProlect FIXTURES (Individual) QTY PRICE AMT
I Job Sink 9.00
Address Street Address - Suite Lavatory 9.00
'v 0 ( 4 c cj1 1 ' NLl inV y Tub or Tub/Shower Comb. 9.00
Bldg s . 90/Staie Zip Shower Only 9.00
_ 1. I'-qa rd D r - 7 ), -/ Water Closet 9.00
Name Prrti Dishwasher 9.00
I M Address Suite Garbage Disposal 9.00
I Owner Mailing
L '1 r1P�b Washing Machine 9.00
fJty/Stats 27p Phone Floor Grain 2' 9.00
WI.UIf alaay r 9.00
t�m�) AA M / - - . 4- - 9.00
Occupant Mainq Address Suite Water Heater - 9.00
Laundry Room Tray 9.00
City/State Zip Phone .- Urinal 9.00 .
Other Fixtures (Specify) - 9.00
_ A(A:J PAr Ptut/ b1 Ael ... 9.00
Contractor Marling Address Suite sane 9.00
( flan Si.J .1 .�Co +l (a, ILJQI. 9.00
(State P oo
I Or. T1r(;2- (C j (o I(e(o 9.00 -
I�G. '� 9.00
Oregon Const Cont. Board Lisa Exp. Date
Mack Copy of 1R 6 1, - 9.00
Coined Plumbing Lip. C Exp. Date _ Sewer - 1st 100' 30.00
Licenses '3 -1 PE
Sewer - each additional 100' 25.00
COT Business Tax or Metros Exp. Date Water Service - 1st 100' 30.00
Name
Water Service - each additional 200' - 25.00
f Architect Storm & Ram Drain - 1st 100' 30.00
Of
Mailing Address Sc .ie Storm & Rain Drain - each additional 100' 25.00
Mobile Home Space 25.00
Engineer C:yiState Zip Phone Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Device
• I Describe work New 0 Addition 0 Alteration 0 Repair 0 Residential Backflow Prevention Device' :( 15.00
• to be done: Residential 0 Non - residential 0 Any Trap or Waste Not Connected to a Fixture 9.00
• Additional desaipuon of work Catch Basin 9.00
- Insp. of Existing Plumbing I 40.00
per /hr
Specially Requested Inspections 40.00
'existing use of oenhr
waling or property Rain Crain. singie family dwelling 30.00
Proposed use of Grease Traps I 9.00
budding or property
QUANTITY TOTAL
Are you nipping . moving or replacing any fixtures? Yes 0 No 0 Isometric or riser diagram is required if Cuaney Total is 9
Of yes see back of form) 'SUBTOTAL
61
I hereby acknowledge that I have read this application. that the information
given is correct. that I am the owner or authorized agent of the owner. and 5% SURCHARGE '7S
Mat ans submitted are in compliance with Oregon State Laws. /
I Sign re of Owne IAg= Da PLAN REVIEW 25% OF SUBTOTAL
/ o Required only d iteure oy total is > 3
C .ki■ I,� ` �!' TOTAL 5 � 7�
Contact rson Name hone
'Minimum permit fee is 525 + 5% surcharge. except Residential Backflow
Prevention Device. which is 515 • 5% surcharge
i:ldstslplmapp.doc 8/96
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PLEASE COMPLETE AS APPROPRIATE TO PROJECT:
Fixtures to be capped, moved or replaced Qty
Sink
Lavatory
Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain - 2"
- - 3"
. 4" Water Heater - - - - - - --
Laundry Room Tray
Urinal _. -. -
Other Fixtures (Specify) -
- AOMMENTS REGARDING ABOVE: -
CITY OF TIGARD BUILDING INSPECTION NOTICE '
Inspection Line: 639 -4175 Business Phone: 639 -4171
Footing Rain Drain Cover /Service
Foundation Water Line Ceiling
Mech. Shear /Sheath Framing -M- .
PIbg.Und /Flr /Slab Plbg. Top Out Insulation - Elect.
Post/Beam Struct. Mech. Rough -in Gyp. Bd. -Bldg.
San. Sewer Gas Line Appr /Sdwlk Reins.
Other AL-64
Date: tl 2 ) /'f 7 A. i P.M. Entry:
Address: d O ' ic! �� IA �
Tenant: Ste: MST:
BUP:
Con /Own: MEC:
G� PLM
ELC
�.� THE FOLLOWING CORRECTIONS ARE REQUIRED ELR:
ti
Inspector: w /� Date //Z }/7
ROVED DISAPPROVED /CALL FOR REINSP. CF CO
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