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Permit CITY OF TIGARD (0� PLUMBING PERMIT q 41 Permit #: PLM2011 -00254 COMMUNITY DEVELOPMENT f TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503 718 2439 Date Issued: 08/09/2011 Parcel: 2S110DCO2200 Jurisdiction: Tigard Site address: 15570 SW PACIFIC HWY Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2 Project Description: Replace /relocate (3) floor drain /sinks, (1) lay & (1) water closet Add (1) sink. 8/24/11, reprinted to include capping of (2) 2" floor drains and (1) lay 10/12/11, reprinted to add (5) primers. Contractor: TAPANI PLUMBING Owner: TRC MM LLC PO BOX 2350 5973 AVENIDA ENCINAS STE 300 BATTLE GROUND, WA 98604 CARLSBAD, CA 92008 PHONE 360- 687 -3983 PHONE. FAX. 360- 687 -4494 FEES Quantity Description Date Amount 3 ea Floor Drain /Floor Sink/Hub 08/09/2011 $75 06 Specifics: 1 ea Sink 08/09/2011 $25.02 ea Lavatories 08/09/2011 $25.02 Type of Use: COM 1 ea Water Closet 08/09/2011 $25.02 Class of Work: ALT 1 12% State Surcharge - 08/09/2011 $18.01 Type of Const: Plumbing Occupancy Grp: 3 ea Fixture /Sewer Cap 08/24/2011 $75.06 Stories: 9 12% State Surcharge - 08/24/2011 $9 01 Plumbing (manual) 5 ea Primer 10/12/2011 $62 55 8 12% State Surcharge - 10/12/2011 $7 51 Plumbing (manual) Total $322 26 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 issua , or if wo is suspended for more the 180 days ATTENTION Oregon law requires you to follow the rules adopted by the Oregon Uti i y Notification Cent: Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules o direct questions to OU - •y cal no 503 232 1987 or 1 800 332.23 c Is ed By: y / / G Permitt Si , 1 / # 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. CITY OF TIGARD PLUMBING PERMIT ,•` COMMUNITY DEVELOPMENT P ermit #: PLM2011 00254 TIGAI D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 O A al Date Issued: 08/09/2011 Parcel: 2S110DCO2200 Jurisdiction: Tigard Site address: 15570 SW PACIFIC HWY • Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2 Project Description: Replace /relocate (3) floor drain /sinks, (1) lay & (1) water closet. Add (1) sink. 8/24/11, reprinted to include capping of (2) 2" floor drains and (1) lay. - Contractor: TAPANI PLUMBING Owner: TRC MM LLC PO BOX 2350 5973 AVENIDA ENCINAS STE 300 BATTLE GROUND, WA 98604 CARLSBAD, CA 92008 PHONE: 360 - 687 -3983 PHONE: FAX: 360 -687 -4494 FEES Quantity Description Date Amount 3 ea Floor Drain /Floor Sink/Hub 08/09/2011 $75.06 Specifics: 1 ea Sink 08/09/2011 $25.02 1 ea Lavatories 08/09/2011 $25.02 Type of Use: COM 1 ea Water Closet 08/09/2011 $25.02 Class of Work: ALT 1 12% State Surcharge - 08/09/2011 $18.01 Type of Const: Plumbing Occupancy Grp: 3 ea Fixture /Sewer Cap 08/24/2011 $75.06 Stories: g 12% State Surcharge - 08/24/2011 $9.01 Plumbing (manual) Total $252.20 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 No • ation Gen - Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direc questions to OUNC c. •3.232.1987 or 1.800.332.2344. Issue. By: / /' di , Permittee Signature- - - 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. • CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit #: PLM2011 -00254 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/09/2011 Parcel: 2S110DCO2200 Jurisdiction: Tigard Site address: 15570 SW PACIFIC HWY Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2 Project Description: Replace /relocate (3) floor drain /sinks, (1) lay & (1) water closet. Add (1) sink. Contractor: TAPANI PLUMBING Owner: TRC MM LLC PO BOX 2350 5973 AVENIDA ENCINAS STE 300 BATTLE GROUND, WA 98604 CARLSBAD, CA 92008 PHONE: 360- 687 -3983 PHONE: FAX: 360 - 687 -4494 FEES Quantity Description Date Amount 3 ea Floor Drain /Floor Sink/Hub 08/09/2011 $75.06 Specifics: 1 ea Sink 08/09/2011 $25.02 1 ea Lavatories 08/09/2011 $25.02 Type of Use: COM 1 ea Water Closet 08/09/2011 $25.02 Class of Work: ALT 1 12% State Surcharge - 08/09/2011 $18.01 Type of Const: Plumbing Occupancy Grp: Stories: Total $168.13 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or ' • suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility . ification Center. Th. - rules are set forth in OAR 952 - 001 -0010 through OAR 952 -0s :090. You may obtain a copy of the rules or di - ct questions to OUNC : callin.. '' 3.232.1987 or 1.800.332.2344. Is ued By: Permittee •mature: Call 503.639.4175 by 7:00 a.m. for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. 08/24/2011 10:19 3606874494 PAGE 02/02 • "lulmibin2 Permit Application A alep a'-) Peylik)1 PLrn 2.0 r 1 -too 2S( Building Fixtures FOR OFFICE USE ONlN City of Tigard 860 " "ea f ay !� Permit NO,: l��0l� ppo�,s 1 3125 SW W all B lvd., Tigard. OR 97223 • pntct0y; _ s Plan Review Phone; 503,718,2439 Fax: 503,598,1960 DnrotRy, Other Permit No, ^ 1/4,14 ay, j� •1' i •:,:i A R to Inspection Line: 503.639;4175 Datc Rcadyr By; luris: El Sc e. Not Internet: www,tigard- er,gov Notified/Method; Sr.ppientenlnl tntnrmatinn t r , ‘4 ! 'v I ati -7 Wtidt* x+ �•P t (liiV.? , Mm �" , a a,„ ; r ho � �dn 6 ), ' V ^ (l , r 1 ' v.C r� " b e t'ra e,� + r Y � : '- . A . ,, t'�" '4 , , ." 6 j � y '" rl a�,., ci . " :. 1.. + „ •$ kl'a`t: t;.,- r: ., . , .� .. t�.x , : ', � � #,�" ;s .,., .. rr{ `^ "' �•r a a�.�t , •) "I „ ° '* " ❑ New construction Q Demolition For special information use checklist, Descripti _ [ Qty. J Ea. 1 Total g Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 'ft. for each utility connection) � ,;;: ., tPlcia a ' a �" t,""" f ' " 't i SFR (1) bath 312,70 : l ❑ 1• and 2- family dwelling RCommercial /industrial SFR. (2) bath 437.78 ❑ Accessory building ❑ Multi - family SFR (3) bath 500,32 Each additional bath/kitchen 25.02 ❑ Master builder Q Other; _ Fire r ,� s y i , ,.,,: '. ^at',. .w+. i :' ;i: -A',,, �rix� ! d� "� . . r L V .` , S Ilsprinkler 1 "r .. Lk ( sq. Page 5 Job site address: / 5 570 '1v ,�a i f'J-z, /�} Catch basin Or area drain 18.7( City/State/ZIP: )"" // r�7 �/ Drywell, leach line, or trench drain 18.76 ! �!'O' ( t- q b? Footing drain (no. linear ft.: _) Page 2 Suite /bldg, /apt no.; Project name: S jp,i r cl,di t i t] (Ph ttr rvvi vJ R, -9 Manufactured home utilities 50.03 Cross street /directions to, job site; Manholes 18.76 Rain drain connector 18.70 Sanitary sewer (no. linear 1.1,: _) Page 2 - Slums Sewer (no. linear ft.: _) Page 2 Water service (no. linear ft.: _) Page 2 Subdivision: Lot. no.; Fixture or item: Tax map /parcel no,; Backflow preventer 31.27 ;.,,... a 1,,.�x a "�'�.�a� r � rl - t .,�r,� ,,,�g� `3 ;::A- : Backwater valve 12.51 .1; '. . .;∎ iii 3ti 4 :z , , 'I')' 5 Jn • '�1 1 r : - ;/y Clothes was 1 � ' ht^r 25.02 r ES 03____r- 6 d. Dishwasher 25.02 ■ R !± ,l� 0 . . ! l ( ( Drinking fountain _ 25.02 t1� ,�y, Ejectors /sump • 25,02 ] wr y i ri4K Q ,.. ,,, ,.,i 1 "'� rtd�ii ,. ; 1 ti r s'` IIk' J, 'taililk t :l. `.,�i Expansion tank 12.51 Name: 2g__; PIC.. Fixture /sewer cap 25,02 Address: _sQ 42. a ,} Floor drain /floor sink/hub 1P: __ 11 �j Garbage disposal 25.02 City/State/ZIP: V1Ac i • ( 2a / 5 _ Hose bib IIII 25,02 Phoil ► ""}' t5 Z 5ir' i Fax: Ls lcc maker 12 51 c«r 1 i i v.A411 7 ,! ;A, "fit " tf rl ,a ? , ' NE Y 'te a5ti Inter(.eptcn'/ rcasctrap 25.02 Business name. l .6/1..q' M "`�4#4, Medical gas (value: $ ) ■ Page 2 ++ i t Primer 12.51 Contact name: Q 1 � Roof drain (commercial) 12.51 Address: PO &Dye^ 230 d Sink/basin /lavatory 25,02 City/State/ZIP: r+ k 6P014144 OA q$6 0 Solar units (potable water) 62.54 Phone: (360) 6,p7. 9 83 I Fax: _ ( 36(1 )07- I f L Tub /shower /shower pan 12,51 E -mail: .r '0.1. f '& r � iq .C.6+ Urinal 25.02 ' "1.,,. �;A "$qC . r.N t . .,,,y -. :'t !\ .I".t ?'i ';',"t•:c :„ water closet 25.02 ' R Water heater Business name: " G7h. J/f Water 37.52 piping/DWV 56,29 Address: -Q 2, _ 3 sd Other 25.02 - City /State/ZIP: 6. , _,.., i 4 ''' $1.1b Subtotal �,/ 6 Phone; (360) tog,') -. : B Fax: (j ( --)--4. . 4 11' Minimum permit fee: $7250 '75 CC.R Lie,; A ,• Plumbing Lie. nn.: ...,76? p � Plan review (25e /n ofpcnnit fee) Q .O/ Stage surcharge (12% of permit fee) Authori signature . Print name; / _ TOTAL PERMIT FEE F ter. Date :% ^49+2P) 1 This permit: application expire. If a permit in not obtained within 18 days after It boa been arteprcd as complete, "Fee methodology set by Tri- County Building leiluntry Scrvicc nanrd, t:\ ' Noraaormils \PLM1J.PcrmltApp.doc I /01819 /40.4616T(10.02,COM,WI'2n1 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 - 1 s ' 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 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 $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 (ea) 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 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge - 1/2 hour) each additional $100.00 or fraction thereof. 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 Review for Plumbing Installations 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 ❑ Any new commercial building with water service 2" and Jacuzzi/Whirlpool greater, except systems designed and stamped by licensed Car Wash - Each Stall engineer. - Drive Thru ❑ New exterior plumbing site utilities for any complex structure Cuspidor /Water Aspirator as defined in OAR918- 780 -0040. Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities. - Domestic ❑ Any multipurpose fire sprinkler system. Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040. Eye Wash Floor Drain/sink - 2" A Submit 2 sets of plans with any of the above. -3" Isometric or Riser Diagram. Car Wash Drain 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 Shower -Gang -Stall Sink/Lav - Non -food related - Bradley - Commercial -food related - Service Swimming Pool Filter Washer - Cloches *Note: If the fixture work under this permit results in an Water Extractor increase of sewer EDUs, a sewer permit will be issued and Water Closet - Toilet fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. Other Fixtures: I:\ Building \Permits\PLMF - PermitApp.doc 02/24/2011 2 08/09/2011 13:21 3606874494 PAGE 02/02 Plumbing Permit Application • Building Fixtures f. g I•-OR oplA E use ()NIA �� R e ceived �a / Permit No,; E L I / 04 City of Tigard R e ce iv : O r _ '���� 114 ii r 13125 SW Hall Blvd.. Tigard. OR. 97223 Plan Review ' I • ` Phone; 503.7111 -2439 Fax: 503,598,1960 Date /8y; Other Permit No,; I kO Y/ GY,�' Inspection Line: 503.639.4175 Date Ready/By; Iu,;c Ea see rage 2 for T Ci A 'I.tt.E.' Internet: www.tigard- or,gov Notified /Method, pp tiu Iemcntalin(ormntio++ &y'�•,, s �" 3 "1i:P5:, +t �> t 1A6",. ' , ' z 'W yy'��•A � ,�y+i,,, 1µ�;V i; . : .:, J.i 7 t 71 ;µi': yy „e i', , :r •. p a ,� • r� °PY0' h :A.:"t ?, "' .,, :, X r i, " i. ,..n ri' ^ ,;,. 4 � ; N:, _ ,', .' i• , y td .;,, t • y ri „ . � ,. .. w2 ` - ` >r ' , , . 5.1 ∎1 1. ^ For special n(ormanon use checklist 'T S”` ,;rJ�(ir ; . .e, r.:. ,,. , ( New construction ❑Demolition i Description _ply. i Ea, 1 Total g Addition /alteration /replacement. ❑ Other: Ncw I- 2-family dwellings (includes 100 R. for each utility connection) 'i*.V: "'ti*r^" SFR 1 bath 312,70 -, :., „�e,. ».' „ ". , . ,� • "� ;,. . ,�� -.. r,:. :. r = • " ,.,•,''„ , ' a�� ! ' �t , . < ; • . �'' ; ^ ` ; 437.78 . ❑ A I - and 2- family dwelling Commercial /industrial SFR (2) bath ❑ Accessory building ❑ Multi- family SFR (3) bath - 500.32 Each additional hath)kitehen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq, kt.) Page 2 1 k I'7 v y u 3 ; ,'I a l : Sate Udlitiec: l' ,.,'uuw,9wYr c, 4.a,_ , •, . ,., »_, . »"]..n. „ , .,,, , , _, _.><,.id1 Job site addresa: / 55 7p 51.) gan - 6_74. f Catch basin nr ores drain 18.76 f t 9 � E-, V Drywell, leach line, or trench drain 18.76 City /State/ZIP: 7*-,,, _ dt,,,,a w 'Y7 Footing drain (nn, linear ft.: ___) Page 2 tr Suite/bldg /apt. no.: Project name: sa. PrU10,•6 (Phan ¥ 'V J �' Manufactured home utilities 50.03 Cross street /directions to job site: Manholes 18.76 Rain drain connector 1$,76 Sanitary sewer (no. linear ft: _) Page 2 Storm sewer (no. linear R.: ) Page 2 Water service (no, linear ft.: ) Page 2 Subdivision: Lot no.: Fixture or item: Tax map /parcel no.: a // ) :- JC.-co2P-4) Back now preventer 31,27 a,• . ....,. E„ if'0640, ,;, ".. �,:z:: Backwater valve 12.51 . � D .0 off-it p � Clothes washer 25,02 � 5t[.� t {� Fes ' Vt&� 4.�. Dishwasher 25.02 - -. Drinking fountain 25,02 Ejectors /sump 25.02 . _, :; :',•,,,:i .� ,. y ,,° . . , :,:y;, ;is ; `� ,,. ;1, M+ y5di: Expansion tank 2,51 Fixture /sower cap 25.02 Name: ►-�C , Addrefis: ! GV a 1 h k .L Garb drain/floor e d sinkAtub " 25.02 7�j ,p � Garbage disposal 25 -02 City /State /ZIP: Cla .1Ca v►nt.s ( 0 fk 4 / ' ! S Hose bib 25.02 Photi ca — go S' ? — S (Co Fax: F.b }-- b5 7-- j C Ice maker 12.51 .‘ ••.; o ' ` ; "�'�'` [ , Interceptor/grain trap .,:',r .., 'I n" . w.M �' e,:`,. �.at .. w.1, .:, �il��'A': •, . , ,,,, " r. + rV.' . ,` 'Y'"' ... Business name: rer fjarlf am Crn fy Medical gas (value: S ) Page 2 Contact name: Carl `f - r " ° (C :\ . Primer 12.51 , Roof drain (commercial) 12,51 Address: Po 6,- z v) Sink/bastn / .,o_ 25.02 50 -.04 City /State /ZiP: f ik 604k WA 986 Oy Solar units (potable water) 62.54 Phone: (3b0 ) &tr. 3 ci g3 I Fax: : (3b0 ) O C. 4 1 Tub /shower /shower pan 12,51. E -mail: Car f 07 •G® Urinal 25.02 G; :,:1' 99 x?• .iiE ; ;.q ;, A .: . t', a ;,:,ti s,: r:.. ;; Water closet l' 25.02 �,O 'trVy ii,.41 s., - 4 it r) t 4iItT .-' .'u "b ,6 2 �% ) �- e k 4 Water heater 37,52 Business name' _ may ° / 1 , J) b i - Water piping/DWV 56.29 Address: P20 tax Q3e5e> Other: 25,02 City/State /ZIP: - H-e c".'..c.+d 1 L -/ Ectjc' q Subtotal ( • �� to — $ (+1'�� 4 , g Minimum permit fee: $72.50 d — Phone: Ctso) Fax: bq 1 CCB Lie.: s , w , 7/A3 S Plumbing Lic. no.: 77 J 1 Plan review (25% of permit 'Fee) v ---- 8 r ,7// 1P — State surcharge (12% of permit tee) /g D Authorized si g nature: TOTAL PERMIT FEE 7 to '. ► 3 after II has been if a permit. is not nhtninad within 1180 +Inye AY b lk d accepted ae complain, ' rte••: Print name: Dater w `Q) i This per npplicntinn expire. 'Fee. tnei:hndnkagy %ci by Tn•'nunty nuilding Industry Service npnrd, t: tnnitdinstPc nrirF�rt.,Mta.rrmitArt,.dnc I5,n 4 40.46I61't10/02/CoM'Wnn 31 10/11/2011 11 :40 3606874494 PAGE 02/02 . • Nta.miain Permit A Pi Cie_ -- /7.Q I"ev' f 1.1� j -I- PLm 2D --O 2S , Building Fixtures RCEtVED FOR OlFIC 11SIT. ONLY City of Tigard Received < i Datc/B Permit No.: 11 11 13125 SW Hall Blvd,. Tigard, OR 9722 1 2011 Plan Rcvtew I. . Phone: 503 718.2439 Fax: 503.,598,1 950 Dats/13F. Other Permit No , 1 T r': A ( inspection Line. 503.639,4175 -�/ �F TIGARD Date Ready /By him Q see Pnge 2 fnr Internet www.tigarcl- or,gov CITY 1 IA , I Notified /Method: Su. *mental Information t 'tint OF WO — s fit} oirt ❑ New construction 0 on Far special in rtnatinn use checklist. Description 1 Qty. , Ea. f Total Addition /alteration /replacement ❑ Other' Ncw 1- 2- family dwellings (includes 100 ft. for each utilit connection) 'CATiGORV CW CONSTRUCTION SFIt (1) bath 312,70 ❑ I- and 2 - family dwelling Commercial /industrial SFR (2) bath — 437.78 • El Accessory building ❑ Multi - family SFR. (3) bath III III Each additional bath /kitchen 25,02 ❑ Master builder ❑ Other: Fire sprinkler (_ sc1, ft.) Page 2 :.:JOB ST 'IN# O RMA'f`lON. AND LO A'TION . , Site utilities: _ — Iti Job site address: / 55 70 514) ga4 is Catch basin orarca drain 115.7( oil -'-'�" Dr line, or trench drain 18, 76 City/State,/ZIP: 't7 "'pi Or « ,,) ... Footing dram (nn. Iincar P'.: ) =Ma Suite/bldg. /apt- no.: Project name: S0. tUZ9j Plat e r H VIAA �J Raul Manufactured home utilities 50.03 Cross street/directions to job site: ll Manholes 18.76 — Rain drain connector 18 70 Sanitary sewer (no, linear ft.: _ ) Page 2 . .._ Storm sewer (no. linear ft,:) _ Page 2 Water service (no linear fl,: _) Page 2 Subdivision: 7 Lot no.: - Fixture or item; - Tax map /parcel no.: l3ackflow preventer 31.27 . , DEORla'TtON OF WORK . ' , Backwater valve 12,51 I} � � Sk2 � &V - Clothes washer 25 02 1� Dishwasher 25,02 Mill -- ra ii brinking fountain 25,02 Ejectors /sump 25,Q2 =! `Pf P T � 1� . IgP!tr4N7f Expansion tack Name: 11C- Fixture/sewer cap _ 25.02 Address: ' CbG >� _. el � Floor g rain / sink/ltub 25.02 E City/State /7,1p: � t� • � �� --- Garbage flispnsal 25.02 El lose M 7 _ Rose bib 25.02 PhorS - 65 —,S /o i Fax: Fa,'/ liv52 $ icc maker El ' i PPUUUCANT 1 z, 5 i ❑ CONTACT I'tt (�SC1N interceptor/grease lisp MI 11E3 1111 Bus - mesa name: Tr 0411 °7p4-..„iy Medical gas (value. $ ) Papc 2 Contact name: CO, I I INNA ( t� f Primer 12 � p Roof drain (commercial) Address; ,P0 ,: 230 _ Sink/basin /lavatory City /State /ZIP: ` " Re 6 4)/1 986 0 - Solar units (potahlc wattr) 62.54 Phone: (3&D ) 6g- Z� 9g3 Fax:: ( 360 ) � 7— y Tub /shower /shower- pan 12, E -mail: Car I i-f-0 22, i fib4r , - h.\ Urinal 25.02 - .. CONTRACTOR Water closet 25.02 MEM ^ p f Water piping/DWV Water heater 37.52 Business name: . 1 6 P1 � b � „_, Address: [,V • ISO ?, Other: 25.02 ei M C i ty/S ta te/Z JP : -1--*.I - . r , / L.-JAI r $' (00 Subtotal Phone; 'GC') 615`1 —'+1 V3 Fax; (3si ( - ,..44 5 4 Minimum permit fee: 572,50 CCB Lie,: a j A ` Plumbing Lie, no.: ....,20 r _ Plan review (25 "/" of permit fee) Authorized signature: a - State surcharge (12% ofpermit fee) , �>t. TOTAL PERMIT FEE • p / Print name: '10./1%.0 Datu jo- j,,1.2pi I Thiig permit npplicati expire% if a permit ii nat nhtalned within t : n days after it hat been accepted as tetllpietr, "Fee mctlwdoIngy set by Tri•County Building industry Service Board I1Dulldmg \Pcrmlw \PLhtti- ParmuApp,(100 10 /01;05 440-4516111 t/02,'COMIWFH)