Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Permit
14 CITY OF TIGARD PLUMBING PERMIT IIIII f 1 COMMUNITY DEVELOPMENT Permit#: PLM2016 00393 TIGARS) 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/25/2016 Parcel: 1S135BC00700 Jurisdiction: Tigard Site address: 10831 SW CASCADE AVE Project: Rose City Futsal Subdivision: None Lot: None Project Description: Interior plumbing for TI:Adding(1)drinking fountain,(5)2"floor drains,and(1)shower stall;Relocating(1)drinking fountain,(4)non-food related sinks,and(5)water closets;Installing(2)expansion tanks,(1)grease trap,(2)water heaters,200 ft.of sanitary sewer,and 200 ft.of water service;Capping(4)sinks and(4)water closets. Contractor: JH KELLY LLC Owner: ICON IPC PROPERTY OWNER POOL 2 L 2311 E 1ST STREET BY INDCOR PROPERTIES VANCOUVER,WA 98661 2 NORTH RIVERSIDE PLAZA, STE 235 CHICAGO, IL 60606 PHONE: 360-423-5510 PHONE: FAX: 503-285-0812 FEES Quantity Description Date Amount 200 If Water Service 07/25/2016 $100.06 Specifics: 2 ea Drinking Fountain 07/25/2016 $50.04 2 ea Expansion Tank 07/25/2016 $25.02 Type of Use: COM 5 ea Floor Drain/Floor Sink/Hub 07/25/2016 $125.10 Class of Work: ALT 1 ea Interceptor/Grease Trap 07/25/2016 $25.02 Type of Const: 4 ea Sink 07/25/2016 $100.08 Occupancy Grp: 1 ea Tub/Shower/Shower Pan 07/25/2016 $12.51 Stories: 5 ea Water Closet 07/25/2016 $125.10 2 ea Water Heater 07/25/2016 $75.04 1 12%State Surcharge- 07/25/2016 $88.56 Plumbing 8 ea Fixture/Sewer Cap 07/25/2016 $200.16 0 12%State Surcharge- 07/25/2016 $24.02 Plumbing 200 If Sanitary Sewer 07/25/2016 $100.06 Total $1,050.77 Required Items and Reports(Conditions) 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 accordance with 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. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain,gi cop of the rules or direct questions to OUNC by calling 503.232.1987/ :9 9 - .2344. .! Issued By: 409- e..-. ittee Signature: ,V .) mss"'" Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Plumbing Permit Application . e--` 7 i t',... a Building Fixtures FOR OFFICE LSE ONE\ City of Tigard Received 7Date/By: /x.5 `CV /�77 PermitNo.: pL "v( _ ( 3841 13125 SW Hall Blvd.,Tigard,.O `9723 e Phone: 503.718.2439 Fax: Plan Review 3.598.1960 Other Permit No.: p Date/By: 1o(S_' Inspection Line: 503.639.4175 T 1 G A R D Date Ready/By: kris. ® See Page 2 for Internet: www.tigard-or.gov ;. ' ` Notified/Method: jets Supplemental Information TYPE OF WORKrtc .;E Q.U.IA _ FEE* SCHEDULE ❑New construction 0 pemolitiori For special information use checklist. �( • Description I Qty. Ea. I Total 1"r Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) k- s' SFR 1 CATEGORY OF CON&UCTION Obath 312.70 0 1-and 2-family dwelling xrCommercial/industrial SFR(2)bath 437.78 buildingSFR(3)bath 500.32 ❑Accessory 0 Multi-family Each additional bath/kitchen 25.02 ❑Master builder 0 Other: Fire sprinkler( sq.ft.) Page 2 r' JOB SITE INFORMATION AND.LOCATION, Site utilities: Job site address: /0931 0 �S�Dc A/6Catch basin or area drain 18.76 J Drywell,leach line,or trench drain 18.76 City/State/ZIP: 7 6141240 D,eC6,17)1 9 7 22 4/ Footing drain(no.linear ft.:_) Page 2 Suite/bldg./apt.no.: I Project name: ROSE eirtiFUTSII, Manufactured home utilities 50.03 Cross street/directions to job site: 10,2eer7a4,4, iteL Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.: ) Page 2 )dC„,:xy Storm sewer(no.linear ft.:_) Page 2 Water service(no.linear ft.:, .Ct) Page 2 No Aj j, Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 s Backwater valve 12.51 ' DE PTION OF WORK '''''-'141' '� 4,,//��,,//�� _Ap ,'"., -' Q /� �y�/)�7''''' Clothes washer 25.02 U[J W 5,1 , `J!/w0� 1' 404 1�6S! eoa Dishwasher 25.02 Drinking fountain 2 25.02 9) V'.j Ejectors/sump 25.02 .£ .PROPERTY O ...._ u CI TENANT Expansion tank 12.51 Fixture/sewer cap 2�( 25.025 Name: /j fQA Kii LI_ c��'1Su LI- n& '/10 y�C- alto'��v Address: Floor drain/floor sink/hub „...........,S _✓ 25.02 bk y'^ IC Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 EI [ lQNTACT PERSON Interceptor/grease trap ' 25.02 U), 6 L`u Medical gas(value:$ ) Page 2 Business name: k f 12 i -/I Primer 12.51 gGt4 Contact name: l l V /`l t Roof drain(commercial) 12.51 Address: l311 6 �c),2n' S!IME Sink/basin/lavatory ✓ - 25.02 /Dot .Lli City/State/ZIP: VA Y)c o a-v6n W71 Qi t j Solar units(potable water) 62.54 Phone:(61 3) 5 7'3 44,914 Fax::(5 7) .Q r c'v 3, Tub/shower/shower pan L i 12.51 /) -S 1 E-mail: k£.ZT OCA)J tl kg t L l. CO re. Urinal 25.02 �1 Water closet 5 25.02 t `CONTRACTOR S, i I? Water heater 37.52 7 Business name: J �6 Water piping/DWV ...----2a0-1-----56.29 Address: Z3 11 6 F Siarr Other: ............../....... ....------' �,.. � 25.02 City/State/ZIP: !/A r C40 14 .. AJNN qq6 b l --- Subtotal y ,,(J (503) 53(3 /gem ([O3) Zg/. OBI' Minimwnpennitfee: $72.50 'v l Phone: JV ie7 gem Fax: 7 J J CCB Lic.: p//'7 5 c/Li Plumbing Lic.no.. Plan review (25%of permit fee) �/,//� State surcharge(12%of permit fee) < 5; Authorized signature: �' > 3.7- l TOTAL PERMIT FEB/iC50' This permit application expires if a permit is not obtained within 180 days Print name: R,a,N 1'r'Q?....,Q Date:`�.7.... ,z0/6 after it has been accepted as complete. ` *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee: . Footing drain-l•100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer-1st 100' 6 62.54 ) u�-''/ 7,201 and greater $327.54 Sewer-each additional 100' ' 37.52 37. Water Service-1st 100' i♦ 62.54 (y,6X.5-21 Medical Gas Systems: ` . Water Service-each additional 100' I 37.52 .3 7 5;2„ Valuation; Permit Fee: Storm&Rain Drain-1st 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50 Storm&Rain Drain-each additional 100' 37.52 i IA $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for Other Inspections ections or Fees ' Fee ) Total each additional$100.00 or fraction thereof,to h and including$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to (minimum charge-1/2 hour) ,� , . ,and including$25,000.00.. Inspections outside of normal business 90.00/hr $25,001.0 to'1650,000:)L} $319.50 for.thq first$25,000.00 and$1.45 for hours(minimum charge-2 hours) .. .:,. •�qh additiogalii3O'00•or fraction thereof,to Reinspection Fees 90.00/hr anc"including$50,000.00. Additional plan review for revisions 90.00/hr •`.„+ `$50,001.0b"awl up• '':,.:. P. $742.00 for the first$50,000.00 and$1.20 for (minimum charge-1/2 hour) _^ ...cack additional$100.00 or fraction thereof. Subtotal: %+ 'k Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. '',.:..,444. J lan�Review for F mhing Inti ila a• ; Quantity by Fixture Type ai•;1 , . . .,. P review 1S re uire�far any of tyle folio'irig!v, ' ,, ,. r.. Fixture Type for Replace! Please check all that apply. Work Performed: Capped Added Relocate 0 Any new commercial building with water service 2"and Baptistry/Font greater,except systems designed and stamped by licensed Bath: -Tub/Shower , Jacuzzi/Whirlpool engineer. New exterior plumbing site utilities for any,c4 mpl structure Car Wash: -Each Stall ' r ,'''as definedid OAl�9ll1';7g00.040+' -i, 'ii IA. -Drive Thru Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities. Dishwasher: Commercial 0 Any multipurpose fire sprinkler system. Domestic 0 Any complex structure as defined in OAR918-780-0040. Drinking Fountain '. I Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" 4 5. Isometric oJ' a" i* 4>, 0 Isometric or riser diagram islequired for'tlew buildings -Car Wash Drain that-, et the qualifications above. . , r Garbage -Domtai iron-food ! • Disposal: -Domestic food related ` s_ .. - o -Commercial food related -Industrial food related , :".' r "-' •'• t i ' Ice Mach./Refrig.Drains Cbmmenti"regarding fixttite world:yr. Oil Separator(Gas Stan") -f, .` .`` 1,:.. ,' + 4 4,',, • , = i \ Rec.Vehicle Dump Statipn Shower: -Gang • . re -Stall •=h.,' I • i , Sink: -Lav/Bar non-food related 4{ • -Bradley ` • . ,, -Com/Serv/Util food related -Service "' ' *,Note: Ifthe3fixture work smiler this petiri t reshlt$4n an Swimming Pool Filter ,' . i increase of sewer EDUs,a sewer.pernut will,be issued and Washer-Clothes . . 't fees assessed for the sewer increase-mu'st be paid before the Water Extractor Water Closet-Toilet si S plumbing permit can be issued. Urinal - Other Fixtures: . ,t *a I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2 Accumulative Sewer Tally ? ki Tenant Name: ROSE CITY FU'1'SAL SWR# N/A Site Address: 10831.SW CASCADE AVE PLM# 2016-00393 Parcel#: 1S135BC00700 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped#s value count added# added value total#s total values Baptisery/Font 4 0 0 0 0 0 Bath: -Tub/Shower 4 0 0 0 0 0 -Jacuzzi/Whirlpool 4 0 0 0 0 0 Car Wash: -Each Stall 6 0 0 0 0 0 -Drive through 16 0 0 0 0 0 Cuspidor/Water Aspirator 1 0 0 0 0 0 Dishwasher: -Commercial 4 0 0 0 0 0 -Domestic 2 0 0 0 0 0 Drinking Fountain 1 1 1 0 1 1 2 2 Eye Wash 1 0 0 0 0 0 Floor Drain/Sink: -2 inch 2 0 0 5 10 5 10 -3 inch 5 0 0 0 0 0 -4inch 6 0 0 0 0 0 -Car Wash 6 0 0 0 0 0 Garbage Disposal: -Domestic(to 3/4 HP) 16 0 0 0 0 0 -Commercial(to 5 HP) 32 0 0 0 0 0 -Industrial(over 5 HP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 Living Unit 16 0 0 0 0 0 Oil Sep(Gas Station) 6 0 0 0 0 0 Rec.Vehicle Dump station 16 0 0 0 0 0 Shower: -Gang(per head) 1 0 0 1 1 1 1 -Stall 2 0 0 0 0 0 Sink: -Lay/Bar-Non-Food Related 2 4 8 4 8 0 0 0 -Bradley 5 0 0 0 0 0 -Com/Sere/Util-Food Related 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer-Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet-Toilet 6 5 30 4 24 0 1 6 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 10 39 8 32 7 12 9 19 Current Fixture Value 19 divided by 16= 1.188 Current EDU 1 EDU= $5,300.00 Previous Fixture Value 39 divided by 16= 2.438 Previous EDU Change -20 divided by 16= -1.250 over (under) $ (6,625.00) Enter EDU Change Here -1.250 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: ***Credit*** Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 7/25/2016 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I:\Building\Sewer Tally\SewerTallySheet_5300_070116.xlsx City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractortty Staff Check(✓)one REFUND OR Name: % ��r, INVOICE TO: (Business or Individual) / W\ /2/716 / 4 /V L� k(eee Mailing Address: J// tE /L-Tr-.St ,A/ City/State/Zip: /47/6/,, c-tom 716'&/ Phone No.: (v ) 537 619 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): • _. • VOID PERMIT APPLICATION. Mi 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#: n/^1 (,)r6/ -(X)3q3 Site Address or Parcel#: /© 8 3/ 54/ �e�aC�_ Project Name: Aja (, F-6,7-Sed Subdivision Name: Lot#: -- EXPLANATION: .,:6N-11-1,7,1-7br if t � � � 0A,rdJ, -1 .4/-c1 x c"7 "Ulla ,at _ 4.alliflea•LiMii.211167miriaNVIMPIVVII01111iSignature: _ Date: //.j 6, Print Name: 1 } • 1104 , ' 'Refund Policy �te, 1. The city's CommunityDevelopment Director,Building Official or CityEngineer may authorize the refund of: / 2i ekixtv, /L7T • Any fee which was erroneously paid or collected. n7217. , • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or 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 via US postal service. 3. Please allow 3-4 weeks for processing refund requests. / 0 a 0 FOR OFFICE USE ONLY Route to Sys Admin: Date / / /(p By Route to Records: Date // /f /,j By te= Refund Processed: Date 1,/ ///r By 1 Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_092314.doc TIGARD City of Tigard November 14, 2016 JH Kelly Inc. Attn: Rich Ritola 2311 E First St Vancouver,WA 98661 Re: Permit No. PLM2016-00393 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10831 SW Cascade Ave. Project Name: Rose City Futsal Job No.: N/A Refund Method: ® Check#222915 in the amount of$224.13. ❑ Credit card "return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit"receipt in the amount of$ Comment(s): Permit not required for sanitary sewer and water service. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov 1,11 City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: JH Kelly Inc. DATE: 11/7/2016 Attn: Rich Ritola 2311 E First St REQUESTED BY: Dianna Howse Vancouver,WA 98661 - BT TRANSACTION INFORMATION: Receipt#: 405124 Case#: PLM2016-00393 Date: 7/25/2016 Address/Parcel: 10831 SW Cascade Ave Pay Method: CreditCard Project Name: Rose City Futsal EXPLANATION: Applicant applied for sanitary sewer and water service in error. Refund 100%of permit fy+eines. ac Etkibe`c s ®e .' � rite cue# i5ca£ Plumbin• 'emit 230-0000-43101 $200.12 12%State Surchar:e 100-0000-24001 24.01 TOTAL REFUND: $224.13 APPROVALS: SIGNATURES ATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board .,_ FOR TIDEMARK;S'YSTEIs ,ADMIN'ISTRATION`USE O1 Case Refund Processed: Date: ///e//,( By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 Plumbing Permit Application ' , c°--i .7 ♦ .. i,,.. , .. 3 Building Fixtures `' roll orFlci: I SF OM.. Received ,�')'J C1�'Of Tigard Date/By: 7/ 5' /6 ,J - Permit No.: n� l :n l61-q 3 u 13125 SW Hall Blvd.,Tigard, ``972\23 r U tWJI GT S Plan Review Phone: 503.718.2439 Fax .598.1960 Date/13y: Other Permit No.: Internet: ioatim .12_100,501, www: 503.639.4175 r T 11,A RD ;� Date Ready/By: )oris: ® See Page 2 for g g -, _ (WA Supplemental Information Inspection Line: h azd-or. ov k• � Notified/Method:n ie ethod TYPE OF WR1K .� O❑'.l)em litio . ._,�C�E'1 '-., ��\.;n . : in PEE*SCHEDULE ref. ❑New construction For special information use checklist. Description I Qty. I Ea. I Total Addition/alteration/replacement EjOtber: New 1-2-family dwellings(includes 100 ft.for each utility connection) CAU ORY-OF CON&[1Cr1ON ; ' ° SFR(1)bath 312.70 ❑ 1-and 2-family dwelling X Commercial/industrial SFR(2)bath 437.78 ❑Accessory building 0 Multi-family SFR(3)bath 500.32 ❑Master builderEach additional bath/kitchen 25.02 0 Other: Fire sprinkler( sq.ft.) Page 2 "d'u, a,r: i JO$+,SI' kiiNFORMATION AND.LOCA'I'IOI , Site utilities: Job site address: 1093/ S� CASCADE d`/� Catch basin or area drain 18.76 /4 At 1�iO O1E'Goh •i 972-2z, 7 22 z, Footing drain line,ore trench drain 18.76 2 City/State/ZIP: �f Footing drain(no.linear ft.:_) Page 2 Suite/bldg./apt.no.: I Project name: Rose cirtfrUTSxL Manufactured home utilities 50.03 Cross street/directions to job site: 6,„eeeu> z Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:j) Page 2 14C-0.w Storm sewer(no.linear ft.: ) Page 2 Water service(no.linear ft.:Aelk(l;,) Page 2 f) 41y Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 � :,._ - DE .IFTION OF WORK , rx: +(=t Backwater valve 12.51 �Q ��p �O r '4• /`�' /� r',y,�'��`' Clothes washer 25.02 ozD WO.�'P a 5:7;eeey4 1- 404 leesen2oax- Dishwasher / 25.02 Drinking fountain .,,"*" 2,,, 25.02 S`V Li Ejectors/sump 25.02 ?4, ,PROPEgiV O ,i'4'., 4' TENT ' `t`' "# Expansion tank Z 12.51 ,25-:04 Name: A egA JSla`t /I 1Su L�"'/n/ �/� Fixture/sewer cap 25.02 alp, Address: ��{ V Floor drain/floor sink/hub 4-------‘'-,5- 25.02 1,k 5"~.IC Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 ''',47517:7: ❑ [jANTACT PERSON Interceptor/grease trap 1 25.02 G'Z Business name: ,7- f/ k 6 L(tel! Medical gas(value:$ ) Page 2 Contact name: • LGN JJLa Amar 12.51 y Roof drain(commercial) 12.51 Address: L -s 7 I 6 ?�i r S 7S 5t7 Sink/basin/lavatory ;�tt1 25.02 `Qct ,0/ City/State/ZIP: (/A 0 CO fr-V&yz• (,)X 'j L 6/ Solar units(potable water) 62.54 Phone:(C-02 5 79 /�Li I Fax::(5t.49J) Q r 083, Tub/shower/shower pan / 12.51 /4 E-mail: REIT O LACE tT u ice t c,y ao,ti. V Urinal 25.02 Water closet ,� s 25.02 6.Z S )0• CONTRACTOR Water heater Z 37.52 "2s-4)1i Business name: 33 € Ate- _ Water piping/DWV �-L--'$6.29 Address: Z 3'I l 6 i/2S`( Si(5Vr Other: � , 25.02 City/State/ZIP: (/A y)66 t.tVf/f>L �jm qs6 6/ Subtotal y' '.i q Phone:(503) 53 i I,Ji gg'I Fax:(543) zgr.Ogg?? Minimwnpermit fee: $72.50 CCB Lic.: Of f'7 6 yci Plumbing Lic.no.. Plan review (25%of permit fee) „7/// State surcharge(12%of permit fee) i 5, Authorized signature: �L�' ,�l� t v / TOTAL PERMIT FEtp' Print name: RIZ, N (70 44 Date:7... ..zq 6 This permit application expires if a permit is not obtained within 180 days after it bas been accepted as complete. "Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(t0/02/COM/WEB)