Permit Support Document I
Plumbing Permit AimlicahRECEIVED
Building Fixturel MAR 6 2020
City of
Phone 5WTigard Received
13125SW liall,Blvd.,TigantOR 9a>I3iTY OFTIGARD »air- /0/2e. - 41 P. itNo.yys7 p9-aye?
7161439 Fas: 503: DING DIVISION Ptau B awerPermitNo:
IneBy:
T I t L;l+n Inspection Line. 503.639.4175 Date Ready/By brie: 13 Sea Pagel for
Internet: teww,tigardor.gnv Notified/Method. SipPlemeohllefo,madoe
TYPE OF-WORK FEE* SCHEDULE
®New constil ction 0 Darnolition For special tr jornrarton Arse checklist
Description 1 OtY. I Ea. I Total
LI Addition/alteration/replacement 0 Other. New t'2-familydwelings(includes 100 ft.for eacbutility connection)
CATEGORY OF CONSTRUCTION $FR.(I)bath 312.70
mil-and 2-family dwelling I ElCommercial/industrial SFR(2)bath 437.:78
50032
Q Accessory building I Multi•fatnily eacb(tidditional batl><Idtchen -
❑Master builder l 0Other age 2,
. ,
... .Fire sprinkler( sq.ft) - Page 2
JOB SITE INFORMATION AND L.001T1ON Site utilities:
1 ,r Catch basin or vi d a rain t3.76 Job site addrcsa: (319`+ r 1(0�jT}+: 1 Jp,�v _
City/State/ZIP:Tigard,OR 97ZZ4 Drywall,leach line,or trench dram 1.6.76
Fooling drain(no.linear ft.:_) Page 2
Suiteibldg./apt.no.: i Project name:' 1I)et"1'i,r.V.C. ep'5e ii 2- Manufactured home utilities
Cross street/directions to job s#trr Manholes 50.76
_ 18.76 _
,- I Raindrain popttector 18.76
Sanitnry sewer(no.linear it.: ) Page 2
Storm sewer(no.linear ft:__ page) pa 2
watm service(no.linear I:, _ ) Page2
Subdivision W er T enure.4! G2St s . Lot tto.:
. 230 PiritairearItem:
Tax map/pamel no.: I Backflow preventer 31.27
DESCRIP't'1ON or WORK Backwater valve 1251
Vylet Clothes washer 25.02
,1 4 re, 7-b1 O0(�j
C,!T`4 6-zrfs Cr Dishwasher 25.02
/ l/�_ 'Drinking fountain 25.02
Ejectors/sump 25.02
13 PROPERTY O*NER I
0 TENANT Expansion tank 12 51
Name:Polygon�YLB,LLC recture/sewer cap 25.02
Address:703 Broadway St,Ste 510
Floordrain/floorainkilrub 25.02
Gazbage disposal 25.02
City/State/ZIP:Vancouver,,WA 98660 Nasebit 25.02
Phone:(360)695.7700 I Fax:( ) Ice maker_ 12.51
0 APPLICANT 0 CONTACT PERSON buaceptodgrease trap 25.02
Business name:Polygon WLH,LLC Medical.gas(value:S_) Page2
Contact name:Tonja Morris Primer 12.Si
Roof drain(commercial) 12,51
Address:703 Broadway St.,Ste 510 Sink/basin/lavatory 25,D2
....City/State/ZIP:Vancouver,WA 98660 Solar units(potablewater) 6154 '
Phone:(360)695-7700 Fax (360)693-4442 Tub/ahOwer/eltowerpan 12.51
E- l:permtlsubmittals®polygonbomes.com , U.rinid 25,)2
CONTRACTOR Water closet
25.02
�,�� .. •
Wain heater 37.52
Business name:t/ t°�sv `Jt/ /k Wafer t ,o WV
9
Address: Q ,ea,, eil_c+ .P P aYI3 25.02
Other 25.02
City/Statte//ZIP: `(f jG 0�e / I y Subtotal
Phone:�% -) 2,3Sc..e? L/ FarMinimumpermit fee: S72.50
p -- --
CB , f 003 l$i Phmib to. /ing lie.t
L Plan review (25%of permit fee)C Lic
State surcharge(12%of permit fee)
Authorized signature: t Y ..,ems — TOTAL PERMIT FEE
Print name:9teR b111es+�- Gl 1 hetCtif Date: I This permit applluUoa expires if petmlt Is not obtained*Milo 1110 days
J after it has been accepted as complete.
1 -Fee methodology act by'DI-County Building industry Service Board.
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