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1004" ,;4 LADS' MARION DR
CITY OF TIGARD
DEVELOPMENT SERVICES
13125 SW Half Blvd.,Tigard,OR 97223 (503)639.4171
1
CITY OF TIGARD Plumbing application Rec'dBy ']•tV//
3125 SW HALL BLVD. Commercial and Residential Date liec'% w
TIGARD, OR 97223 Date to F -
(503) 639-4171 Date to D T ,
Permit•
Print or Type Related SWR s
Incomplete or illegible applications will not be accepted Called
Name of DeveiopmenVProject FIXTURES r,lndividua., QTY I PRICE rAMT
' .lob Sink _ 9.00
Address Street Address Sutle Lavatory9.00
•, � c I Tub or Tub/Shower Comb. 9 E -
Bldg t Gtpsi Zip Shower Only
J.00
L r II L Water Closet - ~- 9.00
Name . Dishwasher I 9.00
Owner Modklg Address Suite Garbage Disposal 9.00
l In Washing Machine 9.00
I ,;41SLte zip Phone Floor Drain 2' _ 9.06
c. Vd. Y' ` 3- 9.00
I -
`l(1 ,�J1.I?- • _ 9.00
OCCUpant Maibq Addr Suite Water Heater 9.00
Laundry Room Tray
0,00
cltyfstato Zip Phone Unnal 9.00
Na
Other Fixtures(Speaty) 9.00
I � 61l _ 9.00
Contmeor Halting Address Suftli
9.00
(1Q'(-, �t t-iIt - 9.00
GtyrSute hone
_
n P//
( 7 v) h I t 9.00 -
Oregon Const.Cont.Board Lic.s Exp.Date - - -- 9.00
mk-*C*"of - ^ ' 9.00
curmrt Plumbing Li Exp.Dale Sewer- 1st 100' -
C' 30.00
lksna/a Sewer-each additional 100' 25.00
COT Business Tax or Metros Exp.Date Water Service-1 st 100' 30.00
Water Service-each additional 200' 25.00 Name -_ � --
Architect Strum d Rain Orau,- 1st 100' 30.00
or Marling Address Sl-:e Storrs: S Rain Drain-each additional 100' 25.0 u I
Moble Home Space 2500
IEnglneer I C,ryistate -Zip -Phone Commercial Back Flow Prevention Device or Anti- 25.00
Pollution Irevice
oscnbe work New O Addition O -Weration O Repair O Residential Backflxn Prevention Device' 15.00
to be done: Residential O Von-residential O - Any Trap or Waste Not Connected to a Fixture 900
Axddttlonal descnpt.on of work - - --
Catch Basin
Insp of existing Plumbing I 40 00 J
_ perihr
- ------ - Specialty Requested Inspecumns 40.00
cxntrq uss of �oenhr _
-"M or property-- -- ----- Rain Orain.single family dwelling 30.00 -
Proposed use of Grease Traps - 4.09
Dutlding or property.- --
_ QUANTITY TOTAL
Are ya. :apping, moving or replacing any fixtures? Yes Q No O Isometric x riser 109ram o ree_ured 0 Cuanxy Total is >v
pf es sea back of form) _ 'SUBTOTAL C
WI herebv acknowledge that I have read this applicilion.that the infoniation
I given,s correct.that I am the owner or authorized agent of the owner. and -5% SURCHARGE
hat q3ns submilled are to c)molian„e with Oregon State Law- -
Sign lure of OwnenAg ja PLAN REVIEW 25%OF SUBTOTAL I ---
aeauired ontvrhture oty !otal,s>3
,��f , TOTAL
=ontact non Namehone ! r S J
�- 'Minimum permit fee is S25 -5%suicr.arge,except Residential Backflow
Prevention Cevice,which is S 15-595,surcharge
t i 4lsts4)I mapp doc 9/98
PLEA*E COMPLETE AS APPROPRIATE TO PROJECT:
Fixtures to be capped, moved or repiaced Qty
Sink_
Lavatory
Tub or Tub/Shower Combination
Shower Only
WaL`er Closet_ _
Diss iwasher --��
Garbage Disposal
Washing Machine _
Floor Drain 2"
3"
4" —
Water heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
7MMF_NTS REGARDING ABOVE:
CITY OF TIGARD BUILDING INSPECTION NOTICE
Inspection Line: 639-4175 Business Phone: 639-4171
Footing Rain Drain Cover/Service I A
Foundation Water Line Ceiling
Post/Beam Mach, Shear/Sheath Framing -M
Plbg.Und/Flr/Slab Plbg. Top Out Insulation -Elect.
Post/Beam Struct. Mach, Rough-in Gyp. Bd. -Bldg.
San. Sewer Gas Line Appr/Sdwlk Reins,
Other:
Date: — A P.M. (� 1Entry:
Address:
Tenant: _ Ste:_ MST:
_
Con/Own: BUP•
MEC ;
b� PLM'
ELC
THE FOLLOWING CORRECTIONS ARE REQUIRED ELR
UN.
i
Inspector: _ —_ _ Dater
ROVED ----DISAPPROVED/CALL FOR REINSP. CF CO
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