Permit CITY OF TIGARD MECHANICAL PERMIT
I: COMMUNITY DEVELOPMENT Permit#: MEC2022-00402
Date Issued: 5/24/2022
-1-t G A B T3 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1 S135CC05000
Jurisdiction: Tigard
Site address: 11873 SW PENNY LN
Project: ERICKSEN Subdivision: BURT'S LANDING Lot: 2
Project Description: Fuel piping to fire pit.
Contractor: OWNER Owner: ERICKSEN, RICHARD H & SARAH R
11873 SW PENNY LN
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Specifics: Description Date Amount
Fuel Piping 05/24/2022 $14.15
Type of Use: SF 12%State Surcharge-Mechanical 05/24/2022 $10.80
Class of Work: OTR Type of Const: Minimum Fee Adjustment-Mechanical 05/24/2022 S75.85
Occupancy Grp:
Stories:
Fuel
Fuel Types:
Gas Pressure:
Total $100.80
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: ' Permittee Signature:
L �^
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.
Mechanical Permit Application �J/ FOR OFFICE USE ONLY
City of Tigard EC E Bd E D Received r/ `�� + Permit o Mf ) t}�il l
13125 SW Hall Blvd.,Tigard,OR 97223 Date/ey: J / ,-r tl-�.v-1 I�
e 1 Plan Review
I Phone: 503.718.2439 MAY 2 `1 2022 Dale/By Other Pennrt
tiGARD Inspection Line: 503.639.4175 _ Date ReadyBy: tons: I See Paget for
Internet: www tigard-or gOv GiT t�/ 0E-TIGARU Notified/Method: Supplemented Infnerne Lion
f!P1 fllN)r, rT ilg1f N
..,..TYPE OF WORK _ COMMERCIAL FEE*SCHEDULE USE CHECKLIST
❑New construction I7G Addition/alteration/replacement Mechanical permit fees*are based on the value of the work
�r performed_Indicate the value(rounded to the nearest dollar)of
0 Demolition ❑ Other: mechanical materials,e_gupmen_t.labor_overhead.and profit..
iwi CATEGORY OF CONSTRUCTION Value 5
RESIDENTIAL EQUIPMENT/SYSTEMS FEES'
X I-and 2-family dwelling 0 Commercial/industrial 0 Accessory building
For special information use checklist.
❑ Multi-family ❑ Master builder ❑ Other:
Description Qty. Ea. fetal
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Job site address. 1 t 0 73 Sri PeNN Y Lw. Air conditioning 1 46.75
Furnace 100,000 BTU(ductavems) 46.75
City/State/ZIP: _.r,, oh ef 7 21-3 Furnace 100,000-BTIJ(duets/vents) 54.91
Suite/bldg./apt.no.: Project name: i Ins p/.r C. ,r, t&ve— Heat pump 61.06
Cross street/directions to job site: Duct work 23.32
TrC9f�'/l.Dfi Hydronic hot water system 23 32
Residential boiler(radiator or
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: 4-7
IJ 02.E L/fNP1/1•G"1 Lot no.: `_ Other: 23.32
Tax map/parcel no.: Other fuel appliances:
,,,t, nriirm7 Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
-2(i, PO- PIPE-. p 12-0.A't 4AV - �C� -o I Flue vent for water heater or gas
(�- fireplace 2332
i=1/Lfr t7/-r Log lighter(gas) 23.32
Wood/pellet stove 33.39 i
Wood fireplace/insert 23.32 1
Chimney/liner/clue/vent 23.32 A
Of PROPERTY OWNER ❑ TENANT Other: 23.32
Environmental exhaust and ventilation:
Name. i2/Ua*E!2 h f.: Rf LKsl a/ Range hood/other kitchen
Address: //el,73 S(„J 'Y neNtd V equipment 33.39
Clothes dryer exhaust 33.39
City/State/ZIP: I
'/ ie,44.J) 02- er 7 2-2-1 Single-duct exhaust(bathrooms,
Phone:(5(3) 7O7 . '-p1' -/3 Fax ( ) toile[compartments,utility rooms) 2332
Attic/crawlspace fans 23.32
liErAPPLICANT 0 CONTACT PERSON Other: 23 32
Business name: Fuel piping:
514.15 for first four;$4.03 for each additional
Contact name:
J�-IGbt,4QV e.f4/61L5 C/1/. _ _ Furnace,etc.
Address: / J 73 S W p63N,,vY LA, Gas heat pump
City/State/ZIP: el"-G-I�R D C2 A/7 ZZ3 Wall/suspended,/unit heater
1 Water heater
Phone:( ) Fax: :( ) Fireplace _ _ _
E-mail: Range --
Barbecue
CONTRACTOR
-- -- � Clothes dryer4gas)
Business name: e LP Other j f€ p/r I --- -_—
Address: MECHANICAL PERMIT FEES'
Subtotal
City/State/ZIP: Minimum permit fcc($90.00) Gl()._CIL
Phone:( ) Fax ( ) Plan review(2566 of permit lee) {��
State surcharge(12%of permit fee)
CCB lie.: f0'1'AL PERMIT FF.F. �J 4$2--
r
n tho
Authorized signature:
Print name: 2,?-W ti7A days after it has been accepted as complete.
• Fee methodology set by Tri-County Building Industry Service Board
-12 ILkLi;i✓ Date: This permit application expires if a permit is not ohtaine dhi
PlBuilding1Pennits1MEC_PermiiApp_082520.doc 440-4617T(I I/02/COM/W EB)
Application - Cityof Tigard
Permit
Page 2 - Supplemental Information
Commercial Submittal Requirements:
• (2) sets of plans, drawn to scale.
• (2) sets of equipment cut sheets.
• (2) copies of site plan for ground and roof top equipment
location and screening per Tigard development code.
Commercial & Multi-Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to$500.00 Minimum fee$69.06
$500.01 to$5,000.00 $69.06 for the first$500.00 and
$3.07 for each additional $100.00 or
fraction thereof,to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first$5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof,to and including
$10,000.00.
$10,000.01 to$50,000.00 $347.71 for the first$10,000.00 and
$2.54 for each additional$100.00 or
fraction thereof,to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first$50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof,to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first$100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
I\Budding\Permits\MEC PermitApp_082520.doc 2
Property Owner Statement RECEIVED
Regarding Construction Responsibilities MAY z 4 2022
Oregon Law requires residential construction permit applicants who are not licensed wiy.i irep TIGARD
Construction Contractors Board to sign the following statement before a building permift BUILDING 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:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
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.
IGHAi2Q b12/GICSC✓v
Print Name of Permit Applicant
G/��2_2_
Sign re of it Apptic Date
Permit#: /111.3G 97JW—uU'1f)a
Address: /1 x73 S1-i A.tAir Giu
0Q i rti41's1
`Vkl,'uYYJ�,;f
•
Issued by: U 'j ' Date: _3747" 1/4d. itiVt
This Copy for Permit Offices
s `F } Information Notice to Owners About
h�r r Construction Responsibilities
(ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503-947-1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, go online to the Oregon Business
Registry. For questions, call 503-945-8091.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 800-452-0288.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, go online to www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance:As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
PO Box 14140, Salem, OR 97309-5052
Telephone: 503-378-4621 —Fax: 503-373-2007
Website Address: wiww.oregon.gov/ccb
f/property_owner adopted 9-2016 This Copy for Permit