Permit _ q CITY OF TIGARD MECHANICAL PERMIT
fa COMMUNITY DEVELOPMENT Pe
COMMUNITY MEC2021-00887
Date Issued: 11/4/2021
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S1026B00404
Jurisdiction: Tigard
Site address: 12045 SW KAROL CT
Project: Johnson Subdivision: KAROL COURT
Lot: 3
Project Description: (1)stove exhaust fan and(3)mini split heat pumps in kitchen and bedrooms.
Contractor: OWNER Owner: JOHNSON, CLIFFORD A&CYNTHIA LEE
12045 SW KAROL CT
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Specifics: Description Date Amount
Heat Pump 11/03/2021 $183.18
Type of Use: SF Range Hood/Other Kitchen 11/03/2021 $33.39
Class of Work: ALT Type of Const: 12%State Surcharge-Mechanical 11/03/2021 $25.99
Occupancy Grp:
Stories:
Fuel
Fuel Types:
Gas Pressure:
Total $242.56
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: Ho-{1 VaM, De, We. e. Permittee Signature: Qi.t,Apiatica,tiov,„
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
RECEIVED a►
Mechanical Permit Applicatio$OV 12021 full OFFtc F «c ON Pi
City of Tigard Received
. TY OF TIGARU Date/By: II Permit No.:
N . • 13125 SW Hall Blvd.,Tigard,OR 97 � /.� � � ��18�7
SIGN Plan Review
Phone: 503.718.2439 Fax: 503.59$�E1DINr 1. ,,DIVISION Date/By: Other Permit: Mi j�L']t
a (�
1 10 n R D Inspection Line: 503.639.4175 Date Ready/By: Jeri, 1d See Page 2 for
Internet: www.tigard-or.gov Notified/Method: tt /,3 ) — Supplemental Information
TYPE OF WORK FEE' SCHEDULE-USE CHECKLIST
Mechanical permit fees*are based on the value of the work
El New construction VA Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all
0 Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit.
f — Value:$
CATEGORY OF CONSTRUCTION T RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
limit I-and 2-family dwelling ❑Commercial/industrial ❑Accessory building For special information use checklist.
❑Multi-family ❑Master builder 0 Other: Description Qty. ( Ea. I Total
•
N. JOB SITE INFORMATION AND LOCATION Heating/cooling:
`.. , Air conditioning 46.75
Job site address: ) `. )0 .-1,� .0 C r'-y
C Furnace 100,000 BTU(ducts/venrs) 46.75
City/State/Z(P: "�"/C'C1 r-6J a-- , 9 2.2. - , Furnace 100,000+BTU(ducts/vents) 54.91
Suite/bldgJapt.no.: Project name: �(( Heat pump 3 61.06 ill 1 ti
qF-t l L�1 i 1 e�n U t �CZ/ Duct work 23.32
Cross street/directions to job site: GaY.-(L' 5 f- 1-1-2 /- 1- �r \ Hydronic hot water system 23.32
-7 f r / ) ! !'1 Residential boiler(radiator or
t� !:7 /1i.Yu/ �..-t ' 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
Subdivision: Lot no.: Other. 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
( Flue vent for water heater or gas
/ /`>in ! q 44 ,1 e e'. .__)-/-V L./y- ( ()y} l fireplace 23.32
/t r t 7 !1✓:�y.,.e- '�' ti G" 1�i G'lG/.fi- 114. /-f-,✓' /3/e"'t+1�) Sp g lighter(gas) -_ 23.32
l t ood/pellet stove 33.39
l'
t________vC-tjt' J'�l 1,1 -1 � L j- , i Wood fireplace/insert 23.32
'-) ,4, i`p(liil ,. Chimney/liner/flue/vent 23.32
PROPERTY OWNEROther: 23.32
0 TENANT Environmental exhaust and ventilation:
Name: C41 r.l4 re/ LTU k i.5c,7` Range hood/other kitchen 4q
1' equipment _1 33.39 33 31
Address: j).0 t.l5- 5 6L1 �i ,-ez/ --.../--- Clothes dryer exhaust _ 33.39 J
City/State/ZIP: / -u Single-duct exhaust(bathrooms,
C eT,! ' t rt ) 3 toilet compartments,utility rooms) 23.32 k
(5(j?j) L� . 7 • --
Phone: Fax:( ) Attic/crawlspace fans 23.32
0 APPLICANT \ 0 CONTACT PERSON Other: 23.32
ibiltk
�Ipf' Business name: Fuel piping: -
__-______.......__._________- $14.115 for first four,S4.03 for each additional
Contact name: Furnace,etc. _
Address: Gas heat pump
----------- — WalUsuspeuded/unit heater
City/State/ZIP: Water heater__
Phone:( ) Fax::( ) -- Fireplace - —
E-snail: Range
C. nd-/c l,f-e`e�. Gcmca s-t-. net Barbecue
CONTRACTOR Clothes dryer(gas)
Business name: �n / *, Other:
[J W MECHANICAL PERMIT FEES*
Address: Subtotal a
t%tJ .5{�
1 City/State/ZIP: Minimum permit fee($90.00)
-- -- - Plan review(25%of pennit fee)
Phone:( ) Fax:( )_ _ State surcharge(12%of permit fee) t2--,_`7y
CCB tic.: / _ TOTAL PERMIT FEE(:7"'t).S-61
IThis permit application expires if a permit is not obt red within law
///'�//2,2/,// days after it has been accepted as complete.
Authorized signature: l�ti y'J�4 � j"— * Fee methodology set by Tri-County Building Industry Service Board
Print name: 1l Y Li Lt) i�(1 /i l� Date:j O r 3
CJ3uiiding\PermitslMEC_PermitApp_040113.doc 440-4617f(II/02/COM/WEB)
RECEIVED
Property Owner Statement Regarding Construction Responsibilities ++Nov a 202�
Oregon Law requires residential construction permit applicants who are not licensed with tht' Y OF TIGARD
Construction Contractors Board to sign the following statement before a building permit c3WHILIDING DIVISION
issued. (ORS 701.325 (2))
This statement is required for residential building,electrical,mechanical,and plumbing permits.
Licensed architect and engineer applicants,exempt from licensing under ORS 701.010(7), need not
submit this statement.This statement will be filed with the permit.
Please check the appropriate box:
j I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
_ 1 I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
71
up"- br TcA n.s ark
Print Name of Permit Applicant
��� � // /D -- 3) -
Signs i of Permit Ap scant Date
Permit#: /6F
Address:
/ _<�
Issued by: Date: --g'
This Copy for Permit Offices