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Permit (41) CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit#: PLM2018-00123 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/08/2018 T[ ,E g Parcel: 2S113AB00500 Jurisdiction: Tigard Site address: 16083 SW UPPER BOONES FERRY RD 130 Project: Bridgeport Family Medicine Subdivision: FANNO CREEK ACRE TRACTS Lot: PT 37 Project Description: Plumbing fixtures to new tenant: ADD(1)dishwasher,(1)ice maker,(2)lays,(1)break room sink,(2)exam sinks, (1)lab sink,(2)water closets and(1)water heater. Contractor: WESTERN PLUMBING Owner: G&S FC LLC 9460 SW TIGARD AVE SUITE 101 16083 SW UPPER BOONES FERRY RD, TIGARD, OR 97223 STE TIGARD, OR 97224 PHONE: 503-639-5296 PHONE: FAX: 503-684-9015 FEES Quantity Description Date Amount 1 ea Dishwasher 03/23/2018 $25.02 Specifics: 1 ea Ice Maker 03/23/2018 $12.51 6 ea Sink 03/23/2018 $150.12 Type of Use: COM 2 ea Lavatories 03/23/2018 $50.04 Class of Work: ALT 2 ea Water Closet 03/23/2018 $50.04 Type of Const: 1 ea Water Heater 03/23/2018 $37.52 Occupancy Grp: 1 12%State Surcharge- 03/23/2018 $39.03 Stories: Plumbing Total $364.28 Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: .<12- / Permittee Signature: � J /04./(-.9%/G9 i`t✓ Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Plumbing Permit Applicat' .,� E- Building Fixtures tt►u 01 ti( l I .r t►,1 \ City of Tigard RDate/Bal .��>, nnit N • 13125 SW Hall Blvd..Tigard,OR 4722 AR 8 201$ pate/By: � �/�' 5607c2v/� ®�✓/a..,3 Plan Review 1 Other Permit /l�. c '�,' >�IPhone: 503.718.2439 Fax: 503.fip F 1 1 pateBy Inspection Line: 503.639.41l$ ttt:it \ tura Id See Page 2 for Internet: www.tigard-or.gov BUILDING GNotifedMeBod: Supplemental information . TYPE OF WORKEEE RCHEDVLE Q New construction 0 Demolttt."114 rist41 Far special btlormadon use checklist. ti Description I Qty. I Ea. I Total AAddition/alteration/replacement 0 Other: New I-2-family dwellings(includes 100 fl.for each utility connection) CATEGORY OF CO1NstitucfiON SFR(1)bath 312.70 ❑ I-and 2-family dwelling 1 Commercial/industrial I SFR(2)bath 437.78 SFR(3)bath I 500.32 ❑Accessory building 0 Multi-family Each additional bath/kitchen 25.02 ❑Master builder j 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB Si't'e INFORMATION AND LOCATION Site utilities: Job site address: \' QC)OBJ SkN V i (�(y,)y �' S Catch basin or area drain 18.76 ""��"" . Drywell.leach line,or trench drain 18.76City/State/'LIP: ( , Footing drain(no.linear it.:�) Page 2 Suitc/bldg./apt.no.: t3 Project nameex\ NA Manufactured home utilities 50.03 Cross street/directions to job site: ��ACA Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:_) Page 2 Storm sewer(no.linear ft.: ) I Page 2 Water service(no.linear R.: ) Page 2 Subdivision: Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 _, Backwater valve 12.51 DESCRIPTION;OF WORK (��'^^_ : ,-#PLS` O\ ,(O1� Clothes washer 25.02 li ilvl7` 1"` Dishwasher 25.02j;O2 Drinking fountain 25.02 Ejectors/sump - 25.02 0 PROPERTY OWNER ,0 TENANT Expansion tank 12.51 Name: Fixture/sewer cap 25.02 I 1 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: ..... Bose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 IQ,c- 1. APPLICANT E.CONTACT PERSON. : Interceptor/grease trap 25.02 Business name: Q S A u, ► ,\inc, Medical gas(value:$ ) Page 2 Contact name: �_`j.�r►+`��Wr Primer 12.51 �,,���^^ .-�^ ,+� \ Roof drain(commercial) 12.51 Address: C"► A100 I U C' LQ)Jt 1`S�L'\ I U\ Sink/basin/lavatory 25.02 ‘t-L0,11.... ('� City/Stale%LII';, �ti `tet Solar units(potable water) 62.54 Phone:( ) Fax::( ) Tub/shower/shower pan 12.51 li-mail: - Urinal 25.02 tyLk) r1pntu,Inhn ir?C0 CONTRACTOR Water closet '� 25.02 G RRAA vv Water heater 1 37.52 , 1,S2 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 ]D, Phone:(503)639-5296 Fax:( ) Minimum permit fee: $72.50 I C'C'B I.ie.:2439 Plumbing Lia no.:3429PB Plan review (25%of permit fee) State surcharge(12%of permit fee) 35,03 Authorized signature:" OA4 /1 _)1 j TOTAL PERMIT FEE ,JOto IThis permit application expires if a permit is not obtained within 180 days Print name: ` �� l0 Date: Ili `'7 g after it has been accepted as complete. dir 7 l *Fee methodology set by Tri-County Building Industry Service Board. I.`,Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4919T(10/021COM/WEB) lie /e.-ee/37 7i z) s/,//d m • Plumbing Permit Application - City of Tigard Page 2 -Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty Fee tea) Total , Footage:' •Fc>rmit Foie: Footing drain-l"100' 50.03 0 to 2.000 $121.90 Footing drain-each additional 100' 37.522.001 to 3,600 $169.69 13,601 to 7,200 $233.20 Sewer-1st 100' 62.54 17.201 and greater $327.54 1 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 , f 'Valuations , * * 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 $5,001.00 to$10.000.00 $72.50 for the first$5,000.00 and$1.52 for Other Inspections or Fees ' FH Total each additional$100.00 or fraction thereof to 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 $25.001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for hours(minimum charge-2 hours) each additional$100.00 or fraction thereof to Reinspection Fees 90.00/hr and including$50,000.00. Additional plan review for revisions 90.00/hr II $50.001.00 and up $742.00 for the first$50,000.00 and$1.20 for (minimum charge- 1/2 hour) l each additional$100.00 or fraction thereof. j Subtotal: 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*. Quota"by Fixture Type 1 PlanIi mb .1nstallat1ofs Fixture Type for Replace/ I 'Review 'o Plan review is required for any ofthe following. Relocate q Work Performed: Capped Added Baptistry/front ( Please check all that apply. Bath l'ub/Shower 0 Any new commercial building with water service 2"and I -Jacuzzi/whiripcwl greater,except systems designed and stamped by licensed Car Wash -Each Stallengineer. -DriveThru ` ' 0 New exterior plumbing site utilities for any complex structure Cuspidor/Water Aspirator as defined in OAR918-780-0040. Dishwasher -Commercial 0 Medical gas and vacuum systems for health care facilities. -Domestic : 0 Any multipurpose fire sprinkler system. Drinking Fountain ❑ Any complex structure as defined in OAR918-780-0040. Eye Wash Floor Drain/sink -2" Submit 2 sets of plans with any of the above. 4.. Car Wash Drain Isometric o Bier€Diagram ` Garbage Domestic-non-food ❑ isometric or riser diagram is required for new buildings Disposal -Domestic-food related that meet the qualifications above. -Commercial-food related -Industrial-food related Ice Mach./Refrig.Drains Oil Separator(Gas Station) Comments regarding fixture work: Rec.Vehicle Dump Station 1� a E1 Sisk S t\ WQ Shower -Gang 7 (fvC)v r0 US- a 1 *.XL ��><a -Stall Ol ` qq,�� ��i j1 Sink/Lav -Non-food related 5 k `l.'� ����� -'� -Bradley y �.4]�f�Sst\`oe,4Q. `tel_ -Commercial-food related -Seryice swimming Pool Filter I *Note: If the fixture work under this permit results in an Washer-Clothes Water Extractor increase of sewer EDUs,a sewer permit will be issued and Water Closet-Toilet a fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. http:i/www.tigard-or.gov/document-_center/Bui lding/PLMF_PermitApp.dS t Plumbing Permit Application R Er Building Fixtures 1+t1; (1111( 1 I `,I USI ) MAR 2 2201$ Received y i%2q/,TO Cityof Tigard !19.a Permit N INn 131 5W Halll Blvd..'I i ard,OR 97223 •._ a Uatc/By:... -ii-- g pp� t.' Pian Review Phone 503.71$.2439 Fax: 503.59R.19t56 t 1 � �te.R3y Other Perron t 4,4e -©©Q 7 Inspection Line: 503.639.4175LOINf� (.fi v!SI( fti Nr,l) pty to Read !B fi m 0 See Pae 2 for Internet: www.tigard-or.go4' J Notified/Method`.3/ �/V Supplemental Information TYPE OF WORK /L- ''•2?v9- FEE* SCHEDULE El Nov construction 0 Demolition For special Information use checklist. Description 1 Qty. I Fa. 1 Total1.4 Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 II.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 © 1-and 2-Fancily dwelling .Commercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 E3 Accessory building 0 Multi-family Each additional bath/kitchen 25.02 0 Master builder 0 Other: Fire sprinkler( ,sq. . 13 Page 2 JOB SITE INFORMATION,AND LOCATION Site utilities: Catch basin or arta d� ,y ., 18.76 Job site address: 1 ()Cf� U��,�('1 a�_Ge- Q nQ� Drywell.leach lie;ort • eh drain I$:76 City/State/ZIP:• - 1 i Footing dr,in rlO.I' ar R.:_) Page 2 Suite/bldg./apt.no,: i•30 1 Project name:0 4, a, - Man a7 rr . e utilities 50.03 Cross street/directions to job site: i/4/6C- 6e, 18.76 F4/1///,..)/ C. f e Zes dr n connector 18,76 �M/�/ Sa 'ary sewer(no.linear R.:_„_) Page 2 omi sewer(no.linear ft.: ) Page 2 79 Water service(no.linear ft.:_) Page 2 Subdivision: Lot no.:�>v Fixture or item: Tax map/parcel no•: Backflow preventer 31.27 - 1 Backwater valve 12.51 DES+CRI ON OF WORK e✓ t. -, Clothes washer 25.02 _ Dishwasher % 25.02 .rl►. 1 A J/6C) �' A Drinking fountain 25.02 �`s Ejectors/sump 25,02 EY 0 PROPERTY OWNER Q TEK4V9 . Expansionansion tank 12.51 Name: I 1 Fixture/sewer cap 25.02 L......._ F Floor drain/floor sink/hub • 25.02 Address: / y Garbage disposal 25.02 City,/State/ZIP: ax: Hose bib 25.02 Phone:( ) ( ) Ice maker\ 1 12.51 l \ o APPLICANT . 0 cONTAC'C PERSON Interceptor/grease trap 25.02 Business name: I ��jw� ig. Medical gas(value:$ ) Page 2 Contact name: ,i ` `. Ali Primer 12.51 --� Roof drain(commercial) 12.51 MEM Address. • 1. 1 t \%,„. t , • �. �( e, 25.02 • l% , City/State/'LIP: ( lb( ' ! a)3 ,• � 2,)!i -5I91� ( loc-/_c'Ois 12.51 Phone: Fax:: Urinal 25.02 E-mail.*i1 Agi CO U.).' ..is,. . . 6• is Y c A , 6 Water closet 25.02 •• � N 1Acric06.,-�S Water heater , v 37.52 Business name:Western Plumbing,Inc. Water piping/DW V Address:9460 SW Tigard Street,Suite 101 Other: 25.02 l 2„ City/State/ZIP:Tigard,OR 97223 Subtotal Minimum permit fee: $72.501 Phonc:(503)639-5296 Fax:( ) � C'C'13 Lie.:2439 J Plumbing l.ic.no.:3429P6 / Plan review (25%of permit fee) 6171:,/ _ ..t.. _ ,C N , State surcharge(12%of permit fee) 1.31,(Y6,_ Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities QEy. Fee( a Total Squa>r!t�`"Ft otege Permit'Fees' Footing drain-I' 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' 62.54 7.201 and greater $327.54 -Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Valnati to rs Feed . Storm&Rain Drain•lst 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50 Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$.5,000.00 and$1.52 for Other Inspections or Fees .Qty. Fee tea) Total each additional$100.00 or fraction thereof,to 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 tee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to 1 (minimum charge-1/2 hour) and including$25,000.00. Inspections outside of normal business 90.00/hr $25.001.00 to$50,000.00 $379.50 for the first$25.000.00 and$1.45 for ' hours(minimum charge--2 hours) each additional$100.00 or traction thereof,to Reinspection Fees 90.00/hr and including$50,000.00. Additional plan review for revisions 90,00/hr550.001.00 and up $742,00 for the first$50.000.00 and$1.20 for (minimum charge- 1/2 hour) I _each additional$100.00 or fraction thereof. i Subtotal: 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*. Quantity,by Fixture Type • Plan I�ie i. r.foPll ibing Il taltalkttions `. Fixture Type for Replace/ Work Performed: Capped Added Relocate Plan review is required for any of the following. Baptistry/Font Please check all that apply. Bath -Tub/Shower 0 Any new commercial building with water service 2"and -Jacuzzi/Whirlpool greater,except systems designed and stamped by licensed Car Wash -Each Stallengineer. -Drive Thru 0 New exterior plumbing site utilities for any complex structure Cuspidor/Water Aspirator as defined in OAR91 8-780-0040. Dishwasher -Commercial 0 Medical gas and vacuum systems for health care facilities. -Domestic t - 0 Any multipurpose lire sprinkler system. Drinking Fountain 0 Any complex structure as defined in OAR9I8-780-0040. Eye Wash Floor Drain/sink -2" Submit a sets of plans with any of the above. 3• ISOrneirk or Rlie1r Diagam: Car Wash Drain Garbage Domestic-non-food in Isometric or riser diagram is required for new buildings 1 Disposal -Domestic-food related that meet the qualifications above. 1 -Commercial-food related -Industrial-food related Ice Mach./Refri,Drains cel S parator(Gas Station) Comments regarding fixture work: Rec.Vehicle Dump Station Shower -Gang -Stall ,,`` /J Sink/I.av -Non-food related -- L�'"S/(1) ' x—x COA-7 CO ,--``C4`1 -Bradley MIX--Cr (1) 4; „5'%r'/jC_ 172_ k1",, -Commercial-food related - -Service Swimming Pool Filter *Note: If the fixture work under this permit results in an Washer Clothes Water Extractor increase of sewer EDUs,a sewer permit will be issued and Water Closet-Toilet .. . 0 fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. -Qtlurf-H tures: t,Jaa .1g http://www.tigard-or.gov/document_center/Building/PLMF_PermitApp.dc}L• H EG El V E `f City of Tigard • (:Oht\II NII\ I)1'\ l l,o1'\II,;N'I' 1)111'\R'I'i\INN'i' MAR 2 9 2018 . II z. Request for Permit Action �1 1.1111A7 l' T`"MS'rq s TIGARD 13125 SW [Tall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.t:igard or.go TO: CITY OF TIGARD Building Division 13125 S\L'Hall.Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 5U3-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner 1 _lpplicant n Contractor ❑ City Staff (:heck(✓)UM. REFUND OR Name: INVOICE TO: Bsincss,,,Indi;du tI) V�Sl4ctx\e\ \\ \ c k :tiMailing Address: CAL\\.Q fj 'SW \ V u cc .S8-L. \�\ City/State/Zip: \\ ' JC\.) 6S-1,_ "(`�\ D3 Phone No.: - }Ici- C'I l� PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): r] CANCEL/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). ❑ RIMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: �L\"\z7.0\%- 0 bl Site Address or Parcel #: MA:'-,S \f[ c ' S q, 1(„d[Vti�\?O l Project Name: p( '(L4 Cer-2.., Subdivision Name: Lot#: 1-''` EXPLANATION: XYYv�� t' . .- 1(Ly.,..Q_ ujQo(, (� `,lc .d C5Y\ Q , Mc' lc �Z ' )4t sin//t$ J U , ,t 3) ,41\7 Signature: , Date: Print Name: t �J I� n Refund Policy I. The city's Cnmmunitc I)cvclopnunt I)irectoi,Building()fficial or(;itV I.ngin(2er may authorize the refund of: • thy fee which was erroneously paid or cnllecred. • 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 Ice for issued permits prior to any inspection requests. 2. UI refunds will be returned to the original pacer in the form of a check via 1's postal service. 3. Please allow 3-4 weeks fire processing refund request.;. f J`0 i l.2- ..B VI e.:3 — ..cc7 . e I " 6 .tr-t) FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date-2 .1 /r B• t—`� Refund Processed: Date y/..b Ar-- f;. Invoice Processed: Date By Permit Canceled: Date �. By = Parcel Tag Added: Date By I:\Building\forms\Regl'cr mit.\rti„n it) i1d.dnr Plumbing Permit Application Building Fixtures (til: t n FI, t l .l t,., City of Tigard I Received 13125 SW Hall Blvd..Tigard,OR 97223 DmdBy; Permit No.: I Phone: 503.71$.2439 Fax 503.598.1960 Pian Review Inspection Line: 503.639,4175 Gate/By: Other Permit No.: f 1,' 1:i PDate Ready/By. luris fd See Page 2 for Internet: www.tigard-or.gOV Notified/Method: Supplemental Information v TYPE OF'WORK I FEE*.SCHEDULE 0 New construction 0 Demolition For special Information use checklist - Description rtilAddition/alteration/replacement ❑Other: I Qty. Ea. I Total New I-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(I)bath 312.70 l'p I-and 2-family dwellingCommerciai/industrial SFR(2)bath 437.78 0 Accessory buildingSFR(3)bath 500.32 0 Multi-family 0 Master builderEach additional bath/kitchen 25.02 0 Other: Fire sprinkler( sq.fl.) Page 2 JOB SITE FORMATION AND LOCATION Site utilities: lob site address: i\Ul ft.J• lt ocisbyka Catch basin or area drain 18.76 � �� Drywall,leach line,or trent . ain 18.76 City/State;/ZIP: I1 ' f _ Footing drain(no,linearAIM_ page 2 Suite/bldg./apt,no.: Project ie:RA\ii,bo .�1►i.. I► Manufactured home itics 03 Cross street/directions to job site: Manholes 18 I8 76 Rain drain co • for 18.76 Sanitary s er(no.linear t).:�) page 2 Storm er(no.linear ft.: ) Page 2 i Wa service(no.linear ft.:_) Page 2 Subdivision: , Lot no.: I . tore or item: Tax map/parcel no.: 'ackflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 25.02 �,,A)6(- ( QprOt Ay-Y Dishwasherg 1 25.02 �0 �( Drinking fountain 25.02 Ejectors/sump 25.02 0 PROPERTY OWNER i 0 TENAN ' Expansion tank 12.51 fI Name: Fixture/sewer cap 25.02 Address: Floor drain/floor sink/hub 25.02 City/State/ZIP: C bage disposal 25.02 Hos .ih Phone:( ) I 25.02 Fax. ] APPLICANT Icemak. \ 12.51 1�.5� ONTAC'i PERSON Interceptor_ -ase trap 25.02 Business name: I \!. �a II Medical gas( tie:$ ) Page 2 Contact name: _ A A ,. , Illir ") Primer 12.51 Address: C . kik -T 4,1„ io . Roof drain(commer -1) MN 12.51 1111111111 , g e Sink/basin/lavatory ...,t ,11111111125.02 t;‘ , City/State/ZIP: 1 t l.(- t 1 .403 Solar units(potable water) 62.54 f Phone:( ) � y; 4 gql _ Fax;:(rr, t;}1 / 2) 'O _q6/5`5 Tub/shower/shower pan 12.51 E-maif'A./. it CO. tat h..ta/ . , iii � A 1 Yg urinal z5.oz j s r. croft Water closet‘, ,all 25.02 ib Business name:Western Plumbing nc. Water heater r\ 37.52 'j'i Water piping/DWV ,56.29 1 Address:9460 SW Tigard Street uite 101 Other: 111 25.02 .....1 City/State/ZIP:Tigard,OR 972 3 Subtotal 4, Phone:(503)639-5296 Fax;( ) Minimum permit fee: .72.50 CCBL.ic.:2439 Plumbing Lie.no.:3429P[3 Plan review (25%of perm) eel • / t State surcharge(I2%of permit fe• ,O' Authorized signatu r / Print name 511611.:- TOTAL.PERMIT FEE ��CSp� g��7 ��v\ 11 Date:�J' Th s gr it is not obtained within ISO days Vt y t *Spied ang ndur 'F Tri-County BuildingIndustry Service Board. I''.Building,Permits\PLMU•PermitApp.doe 1010 t/09 440.46101 10/O/COMnVEa)