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E3J.88 SW DURHAM ROAD
CITY CSF TIGARD
BUII DING PERMIT
DEVELOPMENT SERVICES -.1l'"Pfl IT ' " " ' ' " ' 9UP?r, 0400
13125 SW Hall Blvd,, Tigard,OR 97223 (503)639-4171
DATE ISSUED: 02/28/97
P(iRCEL: 251
I"F- ADDPrSS. . . . 08188 �3t-! 1.11jrH(',M RD
BDI V ISI ON. . . . : ZONING: I -P
f_)CV. . . . . . . . . . .
-----------------
I 73sl JF 7 -LOO P AREAS EXTFFRTOR WALL- CONSTRUCTU"N
Ass or WORK. :ALT FIRST. . . . ICU S f N: S: I HR E: W' i
E F) . :COM SECOND. . . coo sr I-ROIECT OPE'NINO3^
IPE OF CON13T. -.5N . . . 0 sif N: s: E: W.
rJpp', r_1 �:()NST ; FIRE RET? .-
rurnw,y :1 1800 sf ROOr
',CUPANCY LOAD: 12 BASEMENT. : 0 cif AREA SEP. RA'rED:
or?. HT. 171 Gnrmm. . 0 s OCCU 13Er. RATEL:
"MT'!
MEZZ?; REOD SETBACKS-.------ REQUI RED-------------
1h !_m-. o i- ; R. ru*r: o t=! r T P 731:V1- :N l)MnV DET. N
Wrl-L I NO UNIT',: 0 FRNT: 0 ft REAR: 0 ft FIR ALRM:N HNDICP ACC: Y
1117DRMS: 0 13PTI-IS: 0 TM17, GURF(ICF: 0 PRO CORR:hl VIARIJTNG- 17,
mat-4s: Teiiaiit improvement needs mPr_+iA_riic:a1 pet-mit
FEE`i
rnSTTLE typr 7pl0lint I..)y &.4 t.v
00 SW PETERS RD PLCK G4. 03 JMH 02/28/97 97- *17191Oq7
F'"I PU 4 ': I. it 0 JMH 021 '2'A/"37 r)7 -2T1007
RHAM OR 97224 PRMT R 98. 50 JMH 02/28/97 97-891087
one #: 6207�512 ".5 P C T F 4. 7)3 JM11 02/2P 197 97 -?"?11 8 7
171, /"' R L U)W3rAr'r-_
. 00 SW DURHAM ROAD
OR 972124
v n iF # 1:3 95 4. 1If 8r, TnTAI
U REQUIRED INISPECTIONr)
i
permit is issued subject to the regulations contained in the Fr-aming Insp
. ird Municipal Code, State of Ore. Specialty Codes and all other 9heav Insp
;',icable laws. All work will be dodo in a::cordanct with F'Jret-4all. Insp
-,oy#H
. plans. This permit will expire if work is not started Gyp Butrd In -ta
V days of issuance, or if work is suspended for more Final Inspection
1W days,
I Troll 4
CzAll fot inspection 639- 4175,
Commercial Building Permit Application, j l
City of Tigard I
13125 SW Hail Blvd.
Tigard, OR 97223 /� U
(543) 639-4171
Jobsite Address: J� _
Tenant: Suite#
Office Uso OrAl
Valuation:
/ f Z, U Tr _ Plonck/Rec # ,p 7,.
— -�� ,,,,
Ovvner. - i A ti e„� �,+t,�e j — Map & TL # j�7 �
Address: -- Approvals Required
- ---- Planning S;� g6-Q[1ne
Phone. _ o r'A 7? —_ Engineering
Other „r
Contractor:
Address: 0 _
Type of const: _ -/y
— —� Occupancy class: —f
Phone:
Sprinklered? Yes
Contractor's License # / (r h O i �
(a M:spy of cu of Oregon it wse) p : Sq. ft. of project: %�dir5)
Contact name & phonekevat At Story (1st, 2nd, etc.)
Proposed use:
ArchitecUEnginee•:
Previous use:
Address
Note: Plumbing & mechanical plans
must be submitted at time of
building permit application.
Phone: --__ _-b..:-[l •-�y.ttt;_____.__. __ —
JOB DESCRIPTION
J
Applicant Signature & Phone number
Raceived by* Date Received:
Permit # Account Description Amount Amt Pd. Bal. Due
-rJ
bldg. Permit (BUILD) �.)� ,�' ILI-
Plumb. Permit (PLUMB)
Mech. Per., ;it (MECH)
State Tax (TAX)
Bldg:
Plumb:
Mech:
Plan Check (F-LANCK) - 1°5 (�y.03
Bldg:
Plumb:
Mech:
Sewer Connection (SWUSA) _
Sewer Inspection (SWINSP)
Parks Dev Charge (PKSDC)
Residential TIF (TIF-R)
Mass Transit TIF (TIF-MT)
Commercial T;F (TIF-C)
Industrial TIF (TIF-1)
Institutional TIF (TIF-IS)
Office TIF (TIF-0)
Water Quality (WQUAL)
Water Quantity (WQUANT)
Fire Life Safety (FLS)
Erosion Cntrl Permit ;ERPRMT)
Erosion Planck/USA (ERPLAN)
Erosion Planck/COT (EROSN)
TOTALS:
CITY OF TIGARD BUILDING INSPECTION DIVISION
24-Hour Inspection Line: 6394175 Business Phone: 6394171
Dale Requested: _ I'p-zj 9 A.M. P.M. MST:
Location: �L BUR __6 V U
Tenant:_ _ y Suite: Bldg: MEC:
Contractor. 1` PLM:
Phone: _
_
0wDer: ___ Phone: ELC:
ELR:
SIT: _
BUILDINGDG 't) PLUMBING MECHANICAL ELECTRICAL SITE
Site osdBeam Post/Beam Post/Beam Cover/Service Sewer/Storm
Footing Roof UndFI/Slab Rough-In Ceiling Water Line
Slab Top Out Gas Line Rough-In UG Sprinkler
Foundation msu ation Sewer Hood/Duct Reconnect Vault
Bsmt Damp Storm Furnace Temp Service MISC.
Masonry Ceiling Rain Drain A/C UG Slab
heath Firc S kir/Alm Crawl/Found Dr I Leat Pump I.ow Volt _
oved-j Approved Approved Approved Approved
EApppr/Sdwlk Not A�roved Not Approved Not Approved Not Approved Not Approved
ri�1AL' FINAL FINAL FINAL FINAL
4 fall for rein ..,� O Reinspection fee of a__ — required before next inspection O Unable to inspect
Inspector: _ _ Date: Page-----of
CITY OF T'IGARD
DEVELOPMENT SERVICES
13125 SW Hall Blvd,, Tigard,OR 972231503;639.4171
CERTIFICATE OF
OCCUPANCY
PERMIT #. . . . . . . : SUP96-0400
DATE ISSUED: 03/25/98
Pf-)RCEL : 2SI1300--00500
_jITE ADDRESS). . . :081 R8 SW DURHAM RD
IDUBD I V I E,I Ori. . . . : 7 ON'I NG- I ---P
BLOCK. . . . . . . LOT. . . . . . . . . . . . . a JURTSDICTIONe TIG
CLASS OF WORK. :ALT
TYPE OF: USE. . . o COM
TYPE OF CONSTR:51%1
OCCUPANCY GRP. -Ft
OCCUPANCY LOAD: 12.
TE=NANT wfw--*. . .
Remarksl Tenant ilflpr-ovpment-
Building C
Owrlprt
DURHAM 11 LLC
8100 5W DURIAAM ROAD
TIGARD OR 97224
Phone #I
Contrartor x
ECCO/9 & 1. XSEr., 66998.*
8100 9W DLIR14AM ROAD
TIGAPI) OR 972c4
Phone #: 639- 1393
Reg #. . : 000639
Thit, C'ertific-ate graritf., occLipancy of the obwie referenced bUildif-Ig Or' pOr-tiOn
thpt,eof and confirms that the building has been inspected for compliance with
the 5t6kte Of 01`90T) COPOCiAltY COdec; f0V the Qr*OUP, occmpAncyl and us'p under
1-- ich the referenced permit was issued.
11MIJ, NO 11%j!:jPFC R il-JILDING I I C—el
POST IN CONSPICUOUS 1:11,.-ACF
CITY OF TIGARD
DEVELOPMENT SERVICES BUILDING PERMIT
F'ERMI'C #. .. .. .. .. . . 1alJF196-0377
13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 DATE ISSUED: 11/22/9E
PARCEL: 2S i. 130P-00500
1 CF_ AL)DRESS. . . : 08186 SW DI_JRHAM RI)
UBDIVISION. . . . : ZONING. I-F'
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . .
REISSUE_.: FLOOR AREAS-----------__ EXTERIOR WALL CONSTRUCTION-
C;I.ASS OF WORK. :NEW F1 RST. . . . : 4.800 s f N: S: 1 HR E: 1 HR W:
'TYPE OF USE. . . :COM SECOND. . . : 0 s PROTECT OPENINGS')-
._.__.._..-_....---. .._.
TYPE. OF CONST. :5N . . . . 0 s f N: S: E: W:
CJCCUPANCY GRP. :F 1 TOTAL---------: 4800 s f ROOF CONST: FIRE RET?:
OCCUPANCY LOAD: 24 BASEMENT. : 0 sf AREA SEP. RATED:
STOR. : 1 HT: 18 ft GARAGE_". . . : 0 s f OCCU SEP. RA TED;
PSMT?: MEZZ?: REDD SETBACKS---------
FLOOR
--._---_-_f=LOOR LOAD. . . . : 0 F s f LEFT: 0 ft RCHT: 0 ft FIR SF'KL.:I1J SMOI' DET. , :N
DWELLING UNITS; 0 FRNT : 0 ft REAR: 0 ft FIR ALRM;N HNDICP ACC:Y
PE.DRMS: 0 BATHS: 0 IMF' SURFACE.: 0 PRO CORR:N PARKING: 0
VALUE. $: 1.00715
Remar-ks : 4800 sq. ft. indl_tstr-i.al/warehotase
iawner..: _.__._.____.____.___.___._______._._......_.___.----._._.___._____--_--____._ FEES
JIM CASTILE type amol.tnt by date r,er_pt
7A1d4i SW PETTERS RD F'L_CK $ 283. 08 JDN 06/06/96 96-2803E4
FIRE $ 174. 20 ,JDN 06/06/96 96-280324
DURHAM OR 97224 PRM $ 435. 50 P 1i/22/96 96-286874
Phoney #: 620--7512 5PCT $ 21. 78 B 11/21 /96 96-286874
EROS $ 40. 00 B 11,122/96 96-2868 74
Contr^ac-tor: ------___.______.__________.____---ERF C' $ 13. 00 P 11 /22/9F.; 96-28687/4
ECCO/S & L LANDSCAPE ERF'C $ 13. 00 B 11/22/96 96-286874
81.00 SW DURHAM ROAD T1 $ 2944. 00 P 11/22/96 96-286874
T-I CARD OR 97224
i-none #: 639-1.395 $ 3924. 56 TOTAL._
Reg #. . : 06,3998
------- REOUIRED INSPECTIONS -This pereit is issued subject to the regulations contained in the Foot/Found Insp
Tigard Municipal Code, State of Ore. Specialty Codes and all other Str,!tc Steel Insp
appl i cable laws. All work will be done in accordance with Re i.n f Steel T n s p _
approved plans. This pewit will expire if work is not started Slab Ins p
within 188 days of issuance, or if worlt is suspended for Bore Fr-aming Insp
than 180 days. Ins!tlation Insp
Shear Wall. Tnsp
Firewall Insp
Gyp Board Insp
Permittee Si. nat!tre : Reinforced r_oncr
Str .tct!tral weldi
Issued By : — h� _— - - —A Final Inspection
Ca' l for, inspection - 639-4175
Commercial Building Permit Application
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 /,�n (y ��(��) X !i�'.• ( 1
(503) 639-4171
Jobsite Address:
Tenant: Suite # Office Use Only
Valuation; 49,00 x $} Planck/RPc #
i Permit# �{ f dD qi /317
Owner: JIM CAS ,1'L L r _ Map & TL -�,I 13 6 -
Address:
- - Apprgvals Required )
VQVzIiAt-I �rz 9-1'2?_q — fanning :. �E`)) q( -
Phone: (e SC, - -1 512 i Engineering(- \-I 11,0 '(X,)2-z
Other
Contractor: IYJ
Addresti 2
Type of const: �V-N
Occupancy class:
Phone: q-13 y per ivy .;i
Sprinklered? Yes
Contractors License # —Qf� �'�4 zM"'^"'4'
(attach copy of current Oregon license) Sq. ft. of project: _-I jA co 2`(^
Contact name & phone: _j'Story (Qst, 2nd, etc.)
Proposed use: j_ IAU I �u -
ArchitectJEngineer: _ �1 LI 1rtyUI R-ItL&t _
JlM AKp► Wy Previous use. I _
Address TIC). ZJ;(
Note: Plumbing & mechanical plans
fi 111IAIV L7 if)p 9 1281 _ must be submitted at time of
building permit application.
Phone lv 2.0 12-OF,Lp
JOB DESCI IPTION. _(1f.�N5T IZl1L�� fi�)V0 Ib r. E_ _N - P-r--A-D
cant Signature & Phone number
Received by _, �_ __ Date Received ____
Permit;$ Account Description Amount Amt. Pd. Bal. Due
Bldg. Permit (BUILD)
Plumb. Permit (PLUMB) _
Mech. Permit (MECH)
State Tax (TAX) %—�� 11Y 7-
Bldg:Bldg: I i�
Plumb:
Mech:
Plan Check (PLANCK)
Bldg:
Plumb:
Mech:
Sewer Connection (SWUSA)
Sewer Inspection (SWINSP)
Parks Dev Charge (PKSOC)
Residential TIF (TIF-R)
Mass Transit TIF (TIF-MT)
Commercial TIF (TIF-C)
Industrial TIF (TIF-1)
Institutional Ti,: (TIF-IS-1
Office TIF (TIF-0)
Water Quality (WQUAL)
',Nater Quantity (WCUANT)
Fire Life Safety (FLS)
Erosion Cntrl Permit (ERPRMT) Y �r
Erosion Planck/USA (ERPLAN) _
Erosicn Planck/COT (EROSN)
TOTALS: � J"���
DATE PIANS CHECK NO.:
PROJECT TIT Z
COUNTYWIDE LO&sL �e Plea
TRAFFIC IMPACT FEE APPUCANT:
WORKSHEET , 1,w, (le L� I
(FOR NON-SINGLE FAMILY USES) SUNG ADDREt f ti� �
_ �?OLS ('' � .
GTY/ZIP/PHONE:
RATE PER �:i v�,��-Vtn T{� -�-727 y
ND USE CATEGORY TRIP TAX MAP NO.:
RESIDENTIAL $159.00 t3 — 4o-x lok SSUO
BUSINESS AND COMMERCIAL .00 IT
NO.ADDRESS: nn ''
OEFIQE 146.00 �I `b SUJ Ix,
INDUSTRIAL 153.00
INSTITUTIONAL $66.00
PAYMENT METHOD:
rASWCHECK
CREDIT INSTITUTIONAL ONLY.
BANCROFT(PROMISSORY NOTE) LAND USE CATEGORY ESCQO"WN.OFUSE EEKOA AM TRIP RA WEEKEND AVC""UP MT
DEFER TO OCCUPANCY IL4b
A k e ur I
BASIS: -16 o-VO(ca-Vi), cwr�G �. 4'400 XP urA C �
Z I14O L-")6 4;r Mave to�&C6J Mq
z you I.}� iC�r ,,JcufL61UG�S i v� J
CALCULATIONS:
fIF- s X01 A* P� � K 1.►ea'r��,S "'em ,t -fir f vats .x lav usa_ OATirY
z.y00th I�VpVeLu�: "f L �,F x Ll Sd x 153.aD I,�q f.�3 I -7'12 00 17--k��P�
7 UI.17 V4 wvlu�l 4 Iv j; TPIROJECT TRIP.?L �r c 111 �`'
(Z 4) I �� G
iEl.'t`.. Z r , �U y oL
ADDITIONAL NOTES: (7 L FOR ACCOUNTING PURPOSES ONLY'
14 p C�'uk-jS 1 1,{l� L��1X1�v1LKA� �Sf1� 9 ROAD AMT.: (V ma
7 L,C O dl TRANSIT AMT.: I
IC �] h��� t�u
utiv�� = 1,41yZ�
Wc1 �,r90 Aye
B .
CC: WASHINGTON COUNTY
TIF NOTEBOOK
form tif10
DATE: PIANS CHECK NO.:
PROJECT TITLE.
CO r TV�IDDE
Si�.
1 AFTIC 111v1.0 ACr FEE APPLICANT:
WORKSHEET
(FOR NON-STNGLE FANULY USES) SUNG AOCRESS:
OTY/ZIP/PIIONF_-
RATE PER
LANDSU E CATEGORY TRIP TAX MAP NO.:
RESIDENTIAL $159.00
BUSINESS AND COMMERC'AL $40.0X1 SITUS NO.ADDRESS:
OEFIQE $146.00 _,,_
INDUSTRIAL $153.00
INSTITLJTICMI, $66.00
PAYMENT METHOD:
CREDIT INSTrUnONAL ONLY.
DANCROFT(PROMISSORY NOTES wAo use CATEGORY OF use r Svc; J�1P�MI
WF.MCEN0�O AVE TPJF
DEFER 1*0 OCCUPANCY 5� 9 ltv.Ve-Z(6 li ./x)
BAS 6 A.X' qv*)i:' �1�1 �� Q f� V-4,1-e'
bU,JI s I� �,Co N!o Cine 60%
CALCULATIONS.
y( l J� T
7� IE- �I�+CJ��.^-�_r ✓'�J l U T��� GSC Y M..Y ( � ,S �1 (milI Cr' \v I p (2eAj1
l3 r 5 Pnoncr t�ir QxMAna�w.
Imo.:
ADDITIONAL NOTES: FOR A=uNnNo Puwr'osEs omLy:
ROAD AMT.:
Z ( I/ I� CrrJA"-) t e W-/LL VV 7 W V f v TR NUT MA77:1
T.:
PREPARED 9r:
C: WASHINGTON COUNTY
TIF NOTEBOOK }(xm!it10
CITY OF TIGARD
+ DEVELOPMENT SERVICES PLUMPING PERMIT
PERMIT t-0. . . . . . . . PLM97-121023
13125 SW Hall Blvd., Tigard,OR 97223 (503)639.4171 DATE ISSUED: 02/03/97
PARCEL: 2S 1 1.3013-00500
)ITE ADDRI SS. . . : Via 168 SW DUPHAM HD
SUBDI V TSTON. . . . : ZONING: I—P
BLOC V. . . . . . . . . . . I_.0 T. . . .. . . . . .
i,LASS OF WORK. . :ALT GARBOGF D l'POSALS. : 0 MOBTLE HOME SPACES. : N
TYPE OF' UCE. . . . :COM WASHING MACH. . . . . . : 0 BACKFLOW PREVNTRS. . : 0
OCCUPONCY GRP. . :F1. FLOOR DRAINS. . . . . . . 0 TRAM'S. .. . . . . . . . . . . . . . 0
STORIES. . . . . . . . = 0 WATER HEATERS. . . . . : 0 CATCH BASINS. . . . . . . : 0
FIXTURES- ____.__._.______ L AIJNDRY TRAYS. . . . . : 0 SF RAIN DROINS. . . . . : 0
SINKS. . . . . . . , . . : 1 URINALS. . . . . . . . . . . . 0 GREP SE TRAPS. . . . . . . . 0
0 GTHFR FIY,TURF_S. . . „ : 0
TUB/SHOWERS. . . . : i SEWER LINE (ft ) . . . : 0
WATER CI. OSETS. . : 0 WATER i._INE (ft ) . •, , : 0
DISHWASHERS. . . . : 0 RAIN DRAIN (ft ) . . . : 0
Remarks : Re PUP'-.1•-0377 shell. and JAUP96--1r400 TI - capping four lays acid two water"
closets from F-'I_.M96-0198 Shower- MIASt he hanclic,ap accessible.
r7wn'. _._._.._._._________---_ ._._.___._.__.______ _____._._.____---____._.___.. FE'FS
JIM CASTILE type amount by date r^ecpt
8100 SW DURHAM RD I,RMT 9 25. 00 P 01=1/03197
5PCT $ 1. 25 R 02/03/97 97-289848
T I GARD OR 97223
Phone #: 639-1395
M 1 CHAF1_ R CO PLUMPING
P 0 PCX 230013
TICARDOR 97281 ----------_--__--.- _._________________-.
Phone #: 639--3199 $ 26. 25 TOTAL
Reg #. . : 67E377
REQUIRED INSPECTIONS
This pProit is issued subject to the regulations cuntained in the Rough—in Insp
Tigard Municipal Code, State of Ore. Specialty Codes and all other PLM/Underfloor,
applicable laws. All work will be done in accordance with Top—out Tnsp _
approved plans. This perait will expire if work is not started Final Inspect i r r
within 188 days of issuance, or if work is suspended for ,ort
than 188 days.
F'er'mittee
Call for inspection — 639-4175
i
'ITY oI= "rIGARD Plumbing Application Recd By-�' kA A, ., gjt
1125 SW HALL BLVD. Commercial and Residential DateRec'd f" G
i IGARD, OR 97223 Date to P E. 774
43) 639-4171 Date to DST
Pennil a �'L,r`i'�'-cx,c 3
Print or Type RelaR >
tsd SW7-4ac7
Incomplete or illegible applications will not be accepted caned rl3r' "'?7—
/ o���- sir(
M..��� : ,777. .cirri/{
Name or Devetopmenuprolect FIXTURES (Individual)
Jab //lir'' ' A,uZ/ /,n � r-"r7 fJ' �a//i Sink — QTY PRICE AMT
,( 9,00 �
Address Street'lddressSuile Lavatory 9.00
7ub or Tub/Shower Comb. —
Bldg 0 City/State Zip Shower Only 9.00
9.00
Naater Closet 9.00
� / / - _
- ,7, ,,)/ (n S Y r C t Dishwasher
Owner MSWV Address --_ 9.00
Swls Garbage Disposal _ 9 00
'�'� •.+/r I
Washing Machme 9.00
CRYMAte Y ZIP Phone Floor pram 2•
/. rid C. .- 9.00
Name 3'_ 9.00
_ 4 900
3ccupent �hQ Address Swte Water Neater --
_ 9.00
LaundryRoom Tray — 9
Gty/Slate Zip Phone Unnal '-
9.00
Name } Other Fixtures(Specify) 9.00
9.00
.ontnctor WV Address Suite
—
1 O7G 7 9.00
GtylstateIP Pjan� rq 9.00,
T/ "air/ -e 4. I- ?i' _ - 9.00
U70n COnst.Cont.Board Lic.s Exp.Date —� 9.00
ArrM Copy of (, 7 7 --
_ 9.00
� Cwrwet Ph+rWrrg Uc.t Exp.Date .Sewer•1st—10W --`---
Lk�neee 30.00
CJT Business Tax or Metro a Sewer-each additional 100' I-Ts00
Exp.Date Water Service •tst 100'
30.00
Name Water Service-each additional 200' 25 00
Architect q„�iri1; f ,,�......, f- Storrs S Rarn Dramist 100' v 10.00
or Mail”Address St,1e Storm&Rain Drain-each additional too' 25
__ Mobile Home Space 25
Engineer Slau ip Phone t,0
C.ty/ Z0
9 Commercial Back Flow Prevention Device or Anti- 25.
• `
Pollution Device
rn _
iM k Yew Qr worAddition O Alteration O Reoair O Residential Backflow Prevention Device' 15.00
done ?esidential O Von-resraential O Any Trap or Waste Not Connected to a Fixture
'conal descnpron of wort - 9 00
Catch Bas n 9 00
Insp.of.5xistirg P!umbrng ---�-
000
_ penhr
3,VV use Of Specialty Requested Inspections T! + 4000
or properly________
rom --- M 1 oerihr
Rain Crain,single family ctweifin9 30 30
P•000sed use of —� — Grease Traps - —I 9 00
ouiiding or properly_
_ CUANTITY TOTAL
Are yon capping, moving or replacing any Ixtures? Yes No p lsamet -r roar legs, s reourea d Cuanty Tow u >9
(If yr+s sae back of form) 'SUBTOTAL
I hereb,actnowlecge that I ha-,e read this acrlication.that the information—
..I.
nformation_..I.;nal I am the owner or authonzed agent of the owner,and 5% SURCHARGE —
mat clans submittec are n cemoliance with Oregon State Laws _ _ �,L
Signature of Owner/agent„ ' Date PLAN REVIEW 25% OF SUBTOTAL I -
� � I �/ ,2,�q 2eaurert,err it!trace any.rotas's-I
/ - —
TOTAL
Contact Person Name Phone - _ , (P G y
permit fee is 225 •S%I narge.excet R,s,
pZ at Bacxflow
?revenbon Cewce.which is 515. 5%sureflarge
.'Astswlmaop d0c 3M
f.
ELEASE CQMPLETEAS APPROPR AT_�E TO PROJE�;
Fixtures to de capped noveci or replaced Qty
Sink
Lavatory y 1
LTub or Tub/Shower Combination
I' Shower Only
}
Water Closet
Dishwasher , ger.v -
Garbage Disposal
Washing Machine
_Floor Drain 2"
3"
4"
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE:
/ \ Accumulative Sewer Tally
Tanant Name: r��5 7 1 u/ I��� This SWR#
Address: t r�� � ,r<,�• This PLM#: Fa M �"a 00,21
Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New
# Value Capped off value added# added #s total
Count off#s count value _values
Baptistry/Font 4
Bath-Tub/Shower 4
_ -Jacuzzi/Whirlpool 4
Car Wash- Each Stall 6 _
-Drive Through 16
Cuspidor/Water Aspirator 1 _
Dishwasher -Commercial 4
-Domestic 2 _ �r
Drinking Fountain 1
Eye Wash 1 —
Floor Drain/sink-2 inch 2
_ -3 inch _ 5
4 inch 6
_ -Car Wash Drn 6
Garbage Disposal � 16 —
_Domestic(to 3/4 HP)
Commercial(to 5 HP) 32
Industrial(over 5 HP) 48
Ice Machine/Refrigerator Drains 1
Oil Sep(Gas Station) 6 0
Rec. Vehicle Dump Station 16 —`�X
Shower- Gang(Per Head) 1 _
-Stall 2
Sink- Bar/Lavatory 2
Bradley 5 _
Commercial3
Service _ 3 _
Swimming Pool Filter 1
Washer-Clothes 6
_Water Extractor 6
Ci-
Water Closet Toilet 6 c"T C 1 (_'
_ _ G
Urinal � F — �—
TOTALS
Total fixture values: `' S divided by 16 = �,`�y 1 EDU
HISTORY
PLM#(16-- ClW EDU# SWR# o PLM# _ __ EDU# _SWR#
"LM# tj F-)I EDU# SWR#_ M_+ PLM# _ ED_U# SWR#
P_LM_# ED_U# _ SW_R# T__ PLM# _ If SWR_#
PLM# EDU# SWR# PLM# EDU# SWR#
\dstskswrtaly doc