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CITY OF TIGARD
DEVELOPMENT SERVICE.
13125 SW Hall Blvd.,Tigard,JR 97223 (503)639.4 71
CITY OF TIGARD plumbing Application Rued By
13125 SW HALL BLVD. Commercial and Residential Dale Recd - c
TIGARD, OR 97223 Date to P E.
Date to DST
(503) 639-4171 Permits (t •n�7-r IT/
Print or Type Related SWR s
Incomplete or illegible applications will not be accepted Called_ =�
Name of DevelopmenUProject FIXTURES (Individual) QTY PRICE AMT
Job
Sink 900
Address Street Address Suite Lavatory 9.00_
i rub or rubrShower Comb.
9.00 �
i Bldg s C tylStale Zips Shower Only 9.001
'7%6�M 1 11,5 Water Closet 901,
Name /���rre //rCr1A�j(J ) / Dishwasher 9.00
Goner Mailing Address Suite Garbage Disposal 9.00
IS- Uu 7, �Yc�f'lMtao( Washing Machine 9.00
City/State Zip PhoneFloor Dram 2' — 9.00
3" 9.00
Name ("`
� r-YkIlk 9.00
Suite
Address Water Heater 9.00
OccupantMe" � -
Laundry Room Tray 9.00
` C ty/State Zip Phone Unnal 9.C,0
Nari>• --- Other Furfures(Specify) ?_0.00
0. ���✓�GVI 9.oa
Contractor Mailing Address Suite 9.00
9.00
C:ty/Stale Zip Phone — — -- —
urulOR q �I(5 GZc'�-Gf��ll 900
Oregon Const.Cont.Board Lie s Exp.Dale 9.00
Asloch copy of r)7 -? :?LJ (2-1—tq—l'17 — 9.00
cwrerml Numbing Lic.aK Exp.Dale Sewer-1 st 1)0' 30.00
Lleeweee Q/ejf 2-'30 ?? Sewer•each additional too•
COT Business Tax or Metros Exp.Date Water Service-1st 100' —1 30.00 —JI
'Jame Water Service•each additional 200' 25 00
Architect Storm 3 Rain Drain- 1st 100' 30.00
or Mailing address Sr.:e - Storm 6 Rain Crain-each additional 100' I 25.00
Moble Home Space -500
Engineer C y,Slate Zip Phone Commercial Back Flow Prevention Cevrce or anti 25.00
Pollution Cewce
Jescrrbe work New O Addition O alteration O Reoair O Residential BacJrflow Prevention Device' 15 00 7
b be dorm Residential O Non.residential O Any Trap or Waste Not Connected to a Fixture 900 I
rddrMorW desrnFt:on of work — —1
Gatch Balm 9.00
Insp.of Existing Plumbing _ I a0 To—
use
- 11 Denhr
-- -- Sceaaity Requested Insoect:ons i +0.00
-Along of �—
oenhr
xxid" or property___ Rain Crain,single family dwelling 30.00
Pmoosed use of Grease`robs ( ?.0C
i biuldinrj Jf pruuerly_ _..— I —
_ QUANTITY TOTAL
A•e o� moving or replacing an fixtures' Yes No' Isornetr c 3r nsw Jugum u reouved 1 cuanrty Taut.s >9
Y DP n9• n9 P 9 Y � ❑ �7
(if yes see back:,f form) _ 'SIJBTOTAL
I her-bv acknowleoge that I ha,.e read this acplication. ,hat the information _
given s wrrect.that I tm the owner or authorised agen'of the owner and 5% SURCHARGE
that clans submitted a v:n compliance with Oregon State Laws _
Signature of OwneriAgent I Date PLAN REVIEW 25%OF SUBTOTAL
i �eaur"onN f!amn ary rein.s>
`�.___,�'1��-.— � `?�_✓'� � TOTAL I �
Contact Person Name ' Phone
_ 'Minimum permit fee is S25•56,1=-+rcnarge. except Residential Backflow
Prevention Cevice.which is S 15•5%surcharge
--�-- Odstskplmapp.doc 9x96
F-LEASE COMPLETE AS APPROPRIATE TO PROJECT:
Fixtures to be capped, moved or replaced Qty
Sink
Lavatory
Tub or Tub/Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain 2"
31'
41'
Water Heater
Laundry Room Tray
-Urinal
Other Fixtures (Specify)
COMMENTS REGARDING ABOVE: