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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN 11 Request Permit Action q 4s TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-o .gov TO: CITY OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor g City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) PA Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): gCANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: 6U3I2„0q0/5—40007 Site Address or Parcel#: /0'l'/9e c (A) nib 1J 67" Project Name: /6A2b �� ` �/�Cbt L/ Subdivision Name: Lot#: EXPLANATION: Jc, £Q K r r. +f E (2.4•-1 r T ,Jor CZ tt,lEto ,9 Plc P E.2 i Y o c 14-r4b /+ Q 12- D r r huzilek. d e,2 Signature: _: Date: 1/44i/5-- Print Name: ---iThf6 - 41: f} 4(DP1,i Refund Policy 1. The Community Development Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80%of the land use application fee for issued permits. d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80%of the building permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Rte to Sys Admin: Date 3 /< MEM Rte to Bid!Admin: Date ..faill B t Refund Processed: Date Ai " By t%/g'f Invoice Processed: Date By Permit Canceled: Date9/S /s B .� Parcel Tag Added: Date By Receipt# Date Method Amount$ I:\Building\Forms\RegPertitAction_062614.doc Plumbing Permit Application�°1 �� Building Fixtures a*1'C j 1(m O1 l it i 1 tii o.r.l City of Tigard l+� Dea Bey / a�1,4-- Permit No.: Oa-lazy 5-- (7s2r IIII • 13125 SW Hall Blvd.,Tigard,OR 97223 G 13 15 Plan Review / •c-c(- ' *7 ■ Phone: 503.718.2439 Fax: 503.598.I�N Date/By: Other Permit No.: Inspection Line: 503.639.4175 {` 'j Date Ready/By: Juris: H See Page 2 for'i i.,�JG v •"j=Tj T!GA R D Internet: www.tigard-or.gov '�j1''� � 1 1��" _ . Notified/Method: Supplemental Information 1 r:,T-(,.ir �,s,It"' _ .' FEE* SCHEDULE TYPE OF W A Ya i �i�'•' p� ❑New construction Demolition For special information use checklist ascription Qty. Ea. Total 14 Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION .. ` ■as SFR(1)bath 312.70 ❑ 1 and 2-family dwelling ]Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 ❑Accessory building ❑Multi-family Each additional bath/kitchen 25.02 ❑ Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: y 1 \ �.,` Catch basin or area drain 18.76 Job site address:' S1 w rn m ,�I∎CO Drywell,leach line,or trench drain 18.76 City/State/ZIP:7\CQ (\}N c171-9)I, Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: I Project name: `>,C-S`.\-(:\ r Ck t 0 l�� Manufactured home utilities _ 50.03 Cross street/directions to job site: QC`` 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 Subdivision: 1 Lot no.: Fixture or item: Tax map/parcel no.: ,..�- I o;pi moo 5c,C Backflow preventer t i 1 31.27 yt,a-r Backwater valve 12.51 DESCRIPTION OF W'ORIi Clothes washer 25.02 ,\C\ X\. ----A \*I j NYVII Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 - [i PROPERTY OWNER ❑ TENANT Expansion tank 12.51 � Fixture/sewer cap 25.02 Name: \ ,\M C- Q. `CACI.-YCA Floor drain/floor sink/hub 1 \ 25.02 ,:�,CD. Address: ,C CP ' \,}J .(k},x('\ I V Garbage disposal 25.02 City/State/ZIP: 1 u ;`;,-Cl. a5 C-r3 ,@ J Hose bib 25.02 Phone (e3)li-`\t-1.-0V() Fax:( ) Ice maker 12.51 ©:`_4PPT,UCJA ❑ CONTACT PERSON Interceptor/grease trap k 25.02 , Medical gas(value:$ ) Page 2 Business name: Primer 12.51 Contact name: Roof drain(commercial) 12.51 Address: Sink/basin/lavatory(11 3 25.02 `}cz), City/State/ZIP: Solar units(potable water) 62.54 Phone:( ) Fax::( ) Tub/shower/shower pan 12.51 Urinal 25.02 E -mail:: � WWaatteer r chleoasteet r 25.02 u ' CONTRACTOR 37.52 Business name:Western Plumbing,Inc. Water piping/DWV 56.29 Address:9460 SW Tigard Street,Suite 101 Other: 25.02 City/State/ZIP:Tigard,OR 97223 Subtotal Ho,sl. Fax:(503)684-9015 Minimum permit fee: $72.50 Phone:(503)639-5296 ( ) 1 0C1 _ Plan review (25%of permit fee) ` , CCB Lic.:2439 Plumbing Lic.no.:3429PB State surcharge(12%of permit fee) D Authorized signature: .1 Q ��.y� II TOTAL PERMIT FEE ^}� L��Y This permit application expires if a permit is not obtained within 180 days Print name 's c\c� 11� Date:`I 1 G,�� after it has been accepted as complete. 1 c} `Fee methodology set by Tri-County Building Industry Service Board. 2. I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10102JCOMlWEB)