Permit Support Document RE
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT "" IVED
N " DEC202013
I Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti � ��TIGARD
TIGARD
g g get I��Nn ntyiSION
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: El Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) h.) •fY y Ti 1Ni6 1 shy 7S S SS
St 11"_
Mailing Address: . ..51? . 5161.1-8 St SSC
City/State/Zip: • A 1K n S w C 5r) D a, G1 Ds1
Phone No.: `Sj CJ j - -Y2,0 - c
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
t yD INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
ZaLt
Permit#: tA5j I ' .. C)0
Site Address or Parcel#: Ot-( ,5 hJ v44 'I )�, !,3 d c,.1 XP
Project Name: G PYY y�'Z c.t v ;i' j
Subdivision Name: Lot#:
EXPLANATION:
Signature: Date: /di - 1')
Print Name: �1�►+ +n, Q, �1
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By 11 Route to Records: Dat .I /„G—
Refund Processed: Date /11/4— By - Invoice Processed: Date 7 By
Permit Canceled: Date /,J ?e y Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120 18.doa/
Building Permit Application trA, I
V ir
Residential 'a` FOR Ol FR(1. I. SF.ON 1.1
City of Tigard Ay
I'llW ., Received ?��/�I
13125 SW Hall Blvd.,Tigard,OR 97223 d: i Date/By: /0//? /T,090-Pte , j`I o 25 y
g 11 C Plan Review l 7 [ �p / r �y�?
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: I Z[� °tfi�/Tt 1 D ^C 4/J
T 1 ,n R D Inspection Line: 503.639.4175 i & 1 i t‘Y Date Ready/By: Juris H See Page 2 for
Internet: www.tigard-or.gov Sr i. Yitt :i 111V ''i Notified/Method: Coy A , 4 Supplemental Information
....;491111:11:41
DATAt 1-v rn 2 F'Al �'Y '`E LING,
®New construction 0 Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTIUJCir ON work indicated on this application.
® 1-and 2-family dwelling 0 Commercial/industrial Valuation: .. 5149-1)ZZI)
ElAccessory building ElMulti-familyNumber of bedrooms: 4
❑Master builder 0 Other: Number of bathrooms: 3
SITE pqp0EmATioN;ANO 440cA`ION Total number of floors: 2 3�2-0
Job site addres.srallp0 SW 74th Ave. New dwelling area: ,('1,,gAgi are feet ES(e co
City/State/ZIP:Tigard Or.97225 Garage/carport area: 536 square feet t-bit
Suite/bldg./apt.no.: Project name:Gerritz partition Covered porch area: )(square feet
Cross street/directions to job site:Taylors ferry to 74th down to 9500 Deck area: / square feet
Other structure area: square feet
REQUIRED DATA:CO MEECL4L--US CXIAST
Subdivision: I Lot no.: '� Permit fees*are based on the value of the work performed.
Tax map/parcel no.:1 Sl 25DB Lot 3100 Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
DESCRIPTION op wow work indicated on this application.
New single Family Home Valuation:
Existing building area: square feet
New building area: square feet
ewe PROPERTY OWNER _* Number of stories:
Name:John Gerritz Ent.,Inc. Type of construction:
Address:333 S.State Street Ste.V-146
Occupancy groups:
City/State/ZIP:Lake Oswego Or.97034 Existing:
Phone:(503)320-7280 Fax:( ) New:
Cs APPLICANT -;; ;. C:1 C NTACT tERSOI
B ,.
Business name:John Gerritz Enterprises,Inc. Structural plan review fee(or deposit):
Contact name:John M.Gerritz FLS plan review fee(if applicable):
Address:333 S.State Street Ste.V-146 Total fees due upon application:
City/State/ZIP:Lake Oswego Or.97034
Amount received:
Phone:(503)320-7280 ( Fax::( ) PIIDT0VOUTAIC SOLAR. ANEL`SS T 4 ES*
pi E-mail:johng@roundstoneproperties.com Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Submit two(2)sets of roof plan with connection details
Business name:John Gerritz Enterprises,Inc. and fire department access,along with the 2010 Oregon
KvAddress:333 S.State Street Ste.V-146 Solar Installation Specialty Code checklist.
Permit Fee(includes plan review $180.00
City/State/ZIP:Lake Oswego Or.97034 and administrative fees):
Phone:(503)320-7280 Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.:43494 Total fee due upon application: $201.60
.�^4.
This permit application expires if a permit is not obtained
„ ,
Authorized signature: 't within 180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry
Print name:John M. erritz Date:, 2'-ar /0_1 1,..j g' Service Board.
I:\Building\Pennits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE FSE OM1.1
City of Tigard ReceivedDate/By: Permit No.:
III ■ 13125 SW Hall Blvd.,Tigard,OR 97223 Associated permits:
2 Phone: 503.718.2439 Fax: 503.598.1960
24-Hour Inspection Line: 503.639.4175 0 Electrical 0 Plumbing 0 Mechanical
I It,NAL)
Internet: www.tigard-or.gov ❑ other:
TEIF FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW )es No NI.
ii
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. 0 0 •
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 0 0
3 Verification of approved plat/lot. 0 0 0
4 Fire district approval required. Name of district: , 0 0 0
5 Septic system permit or authorization for remodel. Existing system capacity . 0 0 El
6 Sewer permit.
0 0
7 Water district approval. ® 0 0
8 Soils report. Must carry original applicable stamp and signature on file or with application. ® 0 0
9 Erosion control 0 plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- ® 0 0
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state ® 0 0
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if ® 0 0
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements
and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction
indicator,lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and
surface drainage.
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size ® 0 0
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, ® 0 0
furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- ® 0 0
floor,wall construction,roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings
and foundation,stairs,fireplace construction,thermal insulation,etc.
15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels. ® 0 0
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and locations;for non- ® 0 0
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing 9 0 1r-
locations.
'locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 0 El
systems,see item 22,"Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ® 0 0
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. ® 0 0
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required ® 0 0
for four or more appliances.
22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or ® 0 0
architect licensed in Ore on and shall be shown to be a licable to theproject under review.
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". 0 0
24 Two(2)sets each are required for Items 16, 19,20 and 22 above. 0 0 0
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 0 0
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 0 0
17 "Drawn to scale"indicates standard architect or engineer scale. 0 0 0
Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard 0 0 0
Street Tree List.
Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 0 0
d protection measures must be drawn to scale and must include the project arborist's signature of approval.
lean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, 0 0 0
uding decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings
lot of record approved prior to September 9, 1995.
its\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
I
1
' Mechanical Permit Application IIIIIIIIIIIIZE=IIIIIIIIIII
City of Tigard Received
Date 43y:
'_:$74q47-Aahr-a645'ef
13125 SW Hall Blvd..Tigard,OR 97223 Plan Review,
1114 It Phone: 503.718.2439 Fax: 503.598.1960 - t. pettily: Oilier Permit:
i „ , 1,, Inspection Line: 503.639.4175 Date Ready/By:• ' Jura: id See Page 2 for
' .''A''
Internet: www tigard-or.gov
' ...., ..,. 4- NotifiedAiethod- Supplemental Information
TYPE OF WORK 1 COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
Mechanical permit fees*are based on the value of the work
rgrNew construction 0 Addition/alteration/replacement pet-harmed.Indicate the value(rounded to the nearest dollar)of all
0 Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit,
Value:$
CATEGORY OF CONSTRUCTION , RESIDENTIAL EQUIPMENT i SYSTEMS FEES*
g 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building For special information use checklist.
0 Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
Heating/cooling:
JOB SITE INFORMATION AND LOCATION -
Airconditioning % 4635
Job site address: C co s.-I (. 1......1 r71 t:-4.-- A-ve- Furnace 100,000 BTU(ducts'vents) I 46.75 ,
City/StatetZIP: T,,,ty-d 0 z qr.) 23 5'
i iFurnace 100,0004-BTU(ductsivents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.: Project name: Ge‘,..„e i 4-1,- eci.i.Y`til,A-- Duct work i 23.32
...,,, 17,-f, A.. .7,-
Cross street/directions to job site: 'rex (...c„ '' T4e,ee• r‘.? - ( D Hydronic hot water system 23.32
V r Residential boiler(radiator or
Cil 5'0 il hydronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended.etc. 46.75
Flue/vent for any of above 23.32
Other: 23.32
Subdivision: G C y-r 7, is 1,, Pc4Yi-i 11' Lot no.:
Other fuel appliances:
Tax map/parcel no.: i 5 i )5(:),a i ..1 3h,O Water heater 23.32
DESCRIPTION OF WORK .Gas firevlacefinsert 33.39
Flue vent for water heater or gas
A
LAL 'P.0 I,luti 1 I-1 cv r v-q.....
4 „c3 fireplace
23.32
Log lighter(gas)
23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
• ,Chimneyilinerlflueivent 23.32
..„ ' Other: 23.32
or PROPERTY OWNER , le TENANT
Environmental exhaust and ventilation:
Name: o V, G4e,f irfil. ,ii‘) 14.A., Range hood/other kitchen
equipment 1 33.39
Address: '3' 3 5. 't A 1 )1, ,yie lie-itiL. Clothes dryer exhaust k 33.39
i...
23,32
City/State/ZIP: i...., k„. e 06%.,,,e. on, 703t./
5.) Single-duct exhaust(bathrooms,i toilet compartments,utility rooms) L.,'
Phone:(6()t•d) 3. ,.c, ..-7 A.90 Fax:( ) Atticicrawlspace fans 23.32
0
APPLICANT 0 CONTACT PEOther
RSON • 23.32
Fuel piping:
Business name: ,Sk tAAQ, hs A 66.i.- $14.15 for first four;$4.03 for each additional
Contact name: '-'5.6 I.1 yyj G e 1 r i -+ 7_,--- Furnace,etc. k .
Gas heat pump
Address:
Walt/suspended/unit heater
City/State/ZIP: Water heater i
i
Phone:( ) Fax::( ) Fireplace
Range
E-mail: Barbecue t
CONTRACTOR Clothes dryer(gas)
Business name:OV-Pti+A, 14pWrit\)6 •k CCI-NZ Other: -
MECHANICAL PERMIT FEES*
Address:CI(4 GC( )'i COC-R )( SI-7 subtotal
City/State/ZIP: Minimum permit fee(590,00)
-Pe-f-C4 Nic,)t CI-7ZZ.C..)
°Ca I Plan review(25%of permit fee)
Fax:(5-0S) .,-SC(A ?.., State surcharge(12%of permit fee)
CCB lic.: .--01 5 .23.?..._ TOTAL PERMIT FEE
This permit applivation expires if a permit is not obtained within ISO
Authorized signature: /WI Fee methoddoaloygys aftsetrIt byhasbeenTr-CountayenceupildtedasinginclmstprlyeteSe.rvice Board
Print name: .---576 _ vvt GPE.+1.,C4 )(1......, Date: to.,.t I
.k‘ ..„
1 Buildm$PtrzaitsNIEC_P. dApp 040113 clac 446-4.171111 02 COM WEB)
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r
Electrical Permit Appiicat• n, 1 r 1 ()R OI ii( l I ,i:0.1 ,
City of Tigard -%,1 - ,,, . r ,
III--
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Related Permit r::
Inspection Line: 503.639.4175 Ready Date/By: lures
i-l C;:'.R D Internet: www.tigard-or.gov Notified/Method:
TYPE OF WORK PLAN REVIEW
.....
New construction 0 Addition/alteration/replacement Please check all that apply(submit 2 sets of plats w/deers checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10.000 amps at 150 volts or 0 Floating buildings.
a 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building less a ground,or exceeds 14,000 O Commer
ngs l•use agriculturnl
amps for all other installations. buildidings.
❑Multi-family 0 Master builder 0 Other. Cl Fire pump. 0 installation of ISO KVA or
JOB SITE INFORMATION AND LOCATION 0 Emergency system larger separately derived
0 Addition of new motor loaf of system.
Job#: Job site address: soy s%A) 7 L <i vt., 100HPormore. D A" E "I-Z""t•3
e -. Cl Six or more residential units. occupancy.i
City/StateJZIP: t 4 c,, V/i ov-i-7.-:7, ❑Heahh•are facilities. ❑Recreational vehicle parks.
❑Supply voltage for moe than
Suite/bldg./apt #: Project name: Ge�,r y�-t Vol.lit 1------ 0 Hazardous or eerier 6s.
❑Service or feeder 6O0 amtps or more. 6�volts'nominal.
Cross street/directions to job site: �AY L..csvS i e vey . -y FEE SCHEDULE
Description I Orr. I Each I Total I •
New residential single-or multi-family dwelling unit.
Subdivision: G C,Cr�A_y epotti't-1 t,.. Lot#: 2 Includes attached garage.
1.000 sq.ft.or less 168.54 4
Tax map/parcel 4: 1%,1 S rb Y; t...0 1 3 i VO Ea.add'!500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
(with above s .) 75.00 2
SI ft
hl e.LI &1'Iv t.,k %'AA-. / / I-`Ar*-0 Limited energy,multi-family 75.0 2
/ residential(with above sq.ft.)
Renewable Energy 0 See Page 2
NoPROPERTY OWNER I ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: bk G e,r-c-41,_ y,n. F,y p v; Sg Y, i'/1K 200 apps or less 100.70 2
Address: 333 IS, S-1-„,-}a SI. 3 to ' \/-. P-4 Le 201 amps to 400 amps 133.56
401 amps to 600 amps 200.34
City/State/ZIP: t,L . ' 0 OS w6 a. Ott-)CP3V 601 amps to 1,000 amps 301.04 2
'J�j� -3Phone:( �;�2 f7-""7 A.g-(> � QFax:( °-.4-- --'_
Over 1,000 amps or volts 552.26 2
L.
Temporary services or feeders installation,alteration,and/or
Email: t 'S C:G0•-`
uw� 3'o W�' O Y rC. relocation
5 59.36 1
Owner installation:'this installation is beingmade on propertythat I own which is not 200 amps or less
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
❑ APPLICANTI ❑ CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
5
Business name: it'fri C CAS (i,,-.,,r above service or feeder fee, 7.42 2
each branch circuit
Contact name: '-•S‘d\et r N..._ Q,K, ,f j 4 I,. B.Fee for branch circuits without
service or Address: branch circuit
fee,first
i 56.18 2
City/State/ZIP: Each add'1 branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( r e ) 3 a, 2,sry Fax::( ) Each manufactured or modular 67.84
dwelling, 2
service and/or feeder
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Elite Electric Group,LLC Sign or outline lighting 67.84 2
Signal circuits)or limited-energy 0 ee Page 2 2
Address: 6150 NE 92nd Dr.#104 panel,alteration,or extension.
City/State/ZIP Portland,OR 97220 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( 503 432-8845 Fax:( 888)901-7914 Investigation(I hr min) 90.00/hr
Email: Industrial plant(I hr min) 78.18/hr
officeaeliteelectricpdx.com Inspections for which no fee is90.00/hr
CCB Lic.: 191274 Electrical Lic.:C639 Suprv.Lic.: 5762S specifically listed('h hr min)
ELECTRICAL PERMTf FEES
Suprv.Electrician siiggnature,required: Subtotal:
Print name: �.G,. y - Date: i J-,/}—I P O Pian Review Requital(25%of permit fee):
State surcharge(12%of permit fee):
•
Authorized signature: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within ISO
Print name: (i�s— 4Y1, G e t r,3-Z Date: 1/ 11-1 O days atter it bas been accepted as complete.
• Number of inspections allowed per permit.
1:1Buildirg\Permus\ELC PeraitApp.ELR ERE.doc Rev 06/17/2015 440.46151(11/05/COM/WEB
I
Plumbing Permit Application
Building Fixtures l(1R Ol tlrl t ,I t,yt
City of TigardReceived
:t II 13125 SW Hall Blvd.,Tigard,OR 223 . fppaianlal: % �1�'� �
Phone: 503.7182439 Fax: 503.598.1960 Other Permit No.:
Inspection Line: 503.639.4175 Date/By:T i{1 it t7 Date ReReady/By: runs: Id See Page2 for
Internet: www.tigard-or.gov N fi e
op ed/Me
thud:
Supplemental Informadua
TYPE OF WORK FEE* SCHEDULE
New construction 0 Demolition For special infornsadon use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement 0 Other. New 1-2-family dwellings(includes 100 ft for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
tg i-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
Accessory building 0 Multi-family SFR(3)bath 500.32
0 Master builderEach additional bath/kitchen 25.02
[(Other: Fire sprinkler C___sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: �^ Catch basin or area drain
l d ki v„, `'moi roc 18.76
CitylState/ZiP: Drywell,leach line,or trench drain 18.76
a.r� 1. �, G i 11 aj Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: i Project name: ee
I rJ�ct�c�'�'L.. i t Yi w t--+-
Manufactured homeutilities--r� �t50.03
f Cross street/directionst� to job site: t l� .o`YS F.CVY y T V r 7(if' r,�,,. Manholes 18.76
T b 9 c D -1 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: ( t4.-,c 4 7 1.1,,, -Q Y \ Lot no.: Fixture or item:
Tax map/parcel no.: ( s i 'As { 1„,0,'3- -1,1 rs'Y Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12 51
L
C,,,,,,,,r i tl c� r, Clothes washer 25.02
1s•s i / r t i Dishwasher 25.02
Drinking fountain 25.02
I Ejectors/sump 25.02
( NANT'ROPERTY OWNER 0 TEExpansion tank 12.51
'••-;co,,,,,,.. Ca,r �1,. tt , r„,,c, Fixture/sewer cap 25.02
Name: ,
-i } Floor drain/floor sink/hub 25:02
Address: .:713 s_ S+s 7 ht: . . .Th, V' j L1 Garbage disposal 25.02
City/State/ZIP: Lys he 05 44 6.s0 a, 1 ow r.f Hose bib 25.02
Phone:(5.7\) 32z-1).Sr C Fax:( ""T Ice maker 12.51
( APPLICANT NTACF PERSON interceptor/grease trap 25.02
Business name: Medical
'� k(r'ti-e tr'},tr (�6� gas(value:$ ) Page 2
Contact name: ''Cy(=.1.,,,,,,_ C(',v{r#t_
12.51
Roof drain(commercial) 12.51
Address:
Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
25.02E-mail: 140 1-e.i..rvA.s 1 two 0v-ti, .rtsl', Ct3 ^^ Urinal
r i
closet
CONTRACTOR 25.02
Business name: aliscope plumbing and construction, Ilc Water heater 37.52
Water piping/DWV 56.29
Address: 18859 SW Butternut St Othe=r 25.02
City/State/ZIP: beaverton or 97078 Subtotal
Phone:(505-927-0713 Fax:( ) Minimum permit fee: $72.50
CCB Lic.: 197728 Plumbing Lic.no.: pb 1249 Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: /Zito' 4. pi/edam-ea-4,i TOTAL PERMIT FEE
Print name: timothy a h Ilen ba ch jr Date: T6ts permit application expires if a permit la not obtained within 180 days
10/16/18 after it has been accepted as mete.
'Fee methodology set by Tri-County Building Industry Service Board,
IABuil lPamits1PLMIA-PermirAppdes 10/01109 440.4616T(1Q+02/CONWJEBI