Permit ,, CITY OF TIGARD MECHANICAL PERMIT
;
COMMUNITY"DEVELOPMENT Permit #:. MEC2009 -00626
13125 SAN Hall Blvd., Tigard OR`97223 503.639.4171 Date Issued: 11 /24/2009
TjGf1RD Parcel 2S1040002100
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Jurisdiction: TIG
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Site address: 13911 SW HILLSHIRE DR
Subdivision: Lot:
Project: SAIER
Project Description: Install gas insert, associated gas piping, and line and cap chimney,
Owner: FEES
KEVIN SAIER Description Date Amount
1391'1 SIN HILLSHIRE DR
TIGARD, OR 97223 Gas Fireplace 11/24/2009 $33.39
Fuel Piping 11/24/2009 $14.15
PHONE: 503 - 590 -1745 12% State Surcharge - Mechanical, 11/24/2009 $8.70
Minimum Fee Adjustment - Mechanical 11/24/2009 $24.96
Contractor:
T & K MECHANICAL
PO BOX 116
FOREST GROVE, OR 97116
PHONE: 503 -844 -9173
FAX: 503- 846 -0195
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Fuel
. Fuel Types: Natural Gas
Gas Pressue:
Total $81.20
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 wit 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 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: _ di ( ` j Permittee Signature: o n_ •
-� �. gy
Call 503.639.4175 by 7:00 a.m. for an inspection'that business day.
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 timelof each inspection.
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New 000stittionAdditiorJaltmharsxm
Mes6mncai penult ims° are based an the value o/ the work
❑ Demolition 4daer_ . hsdisaoe the vatlre (rounded m the nearest dollar) of ell Q tical IDb� and 6t.
CAI DCl`I4
1- and 2- family dwelling Q Commercial/industrial Q building buildin :` • ' r. el ; , l,, +r . _r,x
For verb! brfornsaties cirecidist.
Multi- family 0 Mager halide: ❑ Other: Des. we riatkon Qty. Es. Taal
. .. • - . •. - spasm INFOIRMATION AND ! . - : -`•
Air cm4tianing or heat pump
3 ° 1 ) sit! adimm y c t t k•'■ H r 1 I S i k, 0 0 r
City/State/4P d . ( I - 7 aa3 Fon= 100.000 BTU 14.00
Svi4dbldgJapt, no.: P r(joet na>nc Fuuvace.10D,�r BTU was/ ) 17.90
�.f' �' '� Gas heal 14.00 -
Cross sttecJdhrections to job sit= Duet wok 10:0(1
Hydnunic hat wasp system 14.00
Residential holler Oakum or
bydranic) 14,00
Unit Licata (flit lypc. not electric),
itt4vaU, imdaict aosocodul. ele. 14.00
Ftuelvcnijs,r /ow of above 6.80
Spbdivisierr I La nu.: cow 1000
'fax onspipateel no.:
• ' • • ' • -- DISSCRIFFRON OF WORK . ..- .. _ .. _ ! 0 0 •
I f1 10-:'
COQ`' I in --- CA `- i i' S St -V7 l i ft(? 6 - (' Gk f Rue or yam:heater or gas
r
• . • s , , . - lb ' - Log liiditer (gas) J 0.00
Wood/pellet stag
10.00
Wood 6t ! F
Cbiatit yll
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- - LJ PBS �.. 0 other. !
Name: K P Q ': n i- Yl,l3• ti - V (i 1 G. € .l t' r�
Cty/SiatelZTP: n- .i G r ,4, 0 .1 „ - e_ 0 1--7 3 Clothes 00
_ . milie s
Other: 10.00
TlW iThrss game: —r-i - k 01 Q C '1 Cc Val i t £. i
ccnt ct tlanse ss�a fOr fast rim; SLOG /or nets Atli/load
Address: ? a ci x I v u j •
Furnace, ctF
r heot owns
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tw -'' )'j't L - G l "73 Fe c : ( a� ) . c q (0 0 ( 6 1 7 _ W
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E-mail: Range
CdidSRA4`JTORt Bmbmue
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Bnai7lcss name: ,L -A e 1 C { t , L ' other.
AddrC .PO 13 0 X 1 t (1 _ - P. M:: Y 'IDIS _ FEW _
crgrlStotr P: _ ®' . . -�(' ' 1 Q 0 �Q 1 • A 5dbtor 1 ') ti _ d a
Minimum permit fee ($72:50) --? a `-3 o
Phone: c 5t. t _ q i i 3 ram ( o ( Flat tcview (25% of permit fee)
CCR lie.: ) 1 1 J ( . State barge (1294 of permit fee)
-- TOTAL PERMIT EKE 1 -- 7
Anttwriaed:signetnr+G ���- - Pia •t mph=
e o 1 eenea1 tome Meted m 1ao n
\<..: 7 / tat been aceepted es
1 l z 1(lc rn ( �) Y' Y Li 1 t • A T _ � � 7 J Fee methodology at by Tel-Comfy Fla - t ne Iedustry Semi= Board 6) C
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7_Ifwe iarplew Di I jaw 400 .46 17T tt7A7lcOe,w 1
k f\oc V__ V
keL'449 (506
a City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: T & K Mechanical DATE: 12/11/09
P.O. Box 116
Forest Grove, OR 97116 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 176112 Case #: MEC2009 -00626
Date: 11/24/09 Address /Parcel: 13911 SW Hillshire Dr.
Pay Method: CreditCard Project Name: Saier
EXPLANATION: Per applicant's request as work was already permitted under MST2008- 00155. Refund
80% of permit fees.
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REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example :. [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
Mechanical Permit Fee 2300000 -43102 $58.00
12% State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $500 Professional Staff LJ_�l
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If under $7,500 Division Manager
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date:
By: �.
Case Refund Processed: Date: By: '-
1: \Building\ Refunds \RefundRequest.doc 04 /13/09
Deb 01 09 11:50a Aline wynne 503 - 846 -0195 p.1
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a_ * 2 '`, Con nnlumty Development
+ i l « - Request for Perri it Action
o: RECEIVED
TO: CITY OF TIGARD • () 1 2009
Building Division Services Coordinator QED
13125 SW Hall Blvd, Tigard, OR 97223 CITY OF TIGARD
Phone: 503.718.2430 Fax; 503.598.1960 www.tigard- ot.gciv BUILDING DIVISION
FROM: ❑ Owner k 11
/Contractor 1 Contractor ❑ City Staff
(check one)
REFUND OR Na; me
INVOICE TO: (liwincnaorindividuai) - - - 1 . K qi Q c h o. n j Cs,
Mailing Address: -P 0 ( B o x (t L }
City /State /Zip: (-,-.11-12. cI 4" Co V Q-, 071 e_. '1 i 1 Lo
Phone No.: () 2 (-L- - q i - 73
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Z CANCEL PERMIT APPLICATION.
j REFUND PFJRMIT FEES (attach receipt, if available).
E TNVOTCE FOR FEES DUE (attach case fee schedule and explain below)_
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: M Q_,C D. OG D I - O C) Cp a CP
Site Address or Patcei #: 1 3c1 1 (;) t 1 11 S h 1 Ire . 0-r 3r,or
Project Name: 5R 1 R C
Subdivision Name: Lot #:
EXPLANATION: 1`1;r C\ i AZ C l r ELI d;{ h�� pi c m 1 "7
1 n c l C 1 F c-1 I ) ; -f ( r , cCr-) c I - h - h Q it p_ m 4 ` -
Signature: \Y\ `1 i Date: 1 A - 1- 0
Punt Name: 11'1 , l r\ C^. k tin n
Rcfvtatlit licx
1. The Director or IIvilding Official may author.c the refund nF:
a) any fee which was erroneously paid ne collected.
b) not mote than 86Y of the iand sot applicatoo fee ,r+ort an application is "arid-Klemm or canceled beepe an ny effort h.ss In= cspended.
e) not mac than ltfl% o f t1+t land ' application fec for iaaucd permits.
d) not more than gm nfthe building plan review fee when an applic uton it einetkd before >.ny plan .Bier effort hie been emended.
c) ant more than 8t of the buiidin8 pemti t fee for treued pa+nmits p.ior to any inspection tequcats.
2. Refunds veil bc'muned tc tic original Print in the carne mcthal +n .eh;ch.payment waa received Plcaec allow 1.2 weeps For processing [cirndr.
8 "I t a.al-i. -.- --:M1 r v^r-4e
Rto to S • n r \dmin: Date / Agra ' IMAM Rte to JMd. Adrnia: Dete ®� t r
Refund Processed: Date 1V,A Bye/ Invoice Proccoscd: ` .Date By
Permit Canceled: Dat // B .PI b' - Paxcel Tag Added: Date Ry
Receipt # Datc Method .r\a w amt 1
t: \Sind* ling\ Fnrrns\RogPermitAetion.doe Rev 97 /26/07
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City of Tigard, Oregon ° 13125 SW Hall Blvd. O Tigard, OR 97223 F , L , , , � k '
, ,, �C: ;CC 1 -R b
December 11, 2009 si
T & K Mechanical
P.O. Box 116
Forest Grove, OR 97116
Attn: Alina Wynne
Re: Permit No. MEC2009 -00626
Dear Ms. Wynne:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 13911 SW Hillshire Dr.
Project Name: Saier
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $64.96.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as work was originally permitted under MST2008- 00155.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
1 k, r>
Dianna Howse
Building Division Services Supervisor
Enc.
1: \Building\ Refunds \ Administration \LtrRefund- CancelPerrnit.doc 01/16/07
Phone: 503.639.4171 0 Fax: 503.684.7297 o www.tigard - or.gov o TTY Relay: 503.684.2772
ivuv uo.JLp Aline wynne 503 - 846 -0195 p.1
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• , �� .., `) ),(y, tck_ RECEIVED
NOV 30 2009
L�� ��.. CITY GI TIGARD
BUILDING DIVISION
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11,11 , CITY OF TIGARD RECEIPT
V
a . 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
A &Tri.t k
Receipt Number: 176279 - 12/11/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2009 - 00626 $ - 64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card • 008470 DHOWSE 12/11/2009 $ -64.96
Payor: Alin K Wynn, T & K Mechanical
Total Payments: $ - 64.96
Balance Due: $64.96
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Page 1 of 1
114 CITY OF TIGARD RECEIPT
a
g : 131 25 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 176112 - 11/24/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2009 -00626 Gas Fireplace 2300000 -43102 $33.39
MEC2009 -00626 Fuel Piping 2300000 -43102 $14.15
MEC2009 -00626 12% State Surcharge - Mechanical 1003100 -24001 $8.70
MEC2009 -00626 Minimum Fee Adjustment - Mechanical 2300000 -43102 $24.96
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 008470 LSELLERS 11/24/2009 $81.20
Payor: Alin K Wynne
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1