Permit CITY OF TIGARD MECHANICAL PERMIT
4 t r COMMUNITY DEVELOPMENT Permit #: MEC2010 00197
TIGARD. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Date Issued: 04/30/2010
u ;!s•;a,y!.:x.! Parcel: 2S112CAl2700
Jurisdiction: Tigard
Site address: 15622 SW 76TH AVE
Subdivision: RENAISSANCE WOODS NO. 2 Lot: 51
Project: Neilson
Project Description: Replace gas furnace
Owner: FEES
NIELSON, STEVE AND ANDREA Description Date Amount
15622 SW 76TH AVE
TIGARD, OR 97224 Air Conditioning 04/30/2010 $46.75
Furnaces < 100K BTU 04/30/2010 $46.75
PHONE: Duct Work 04/30/2010 $23.32
Flue Vent for Water Heater or Gas 04/30/2010 $23.32
Contractor: Fireplace
ANCTIL HEATING & COOLING 12% State Surcharge - Mechanical 04/30/2010 $16.82
4320 N WILLIAMS AVE
PORTLAND, OR 97217
PHONE: 503 - 281 -0752
FAX: 503- 282 -5722
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Fuel
Fuel Types: Natural Gas
Gas Pressue:
Total $156.96
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 -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: P' J Permittee Signature: 54.6_ A p p- r n Tom( 1/11
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 time of each inspection.
CEI VED
Mechanical Permit Application - r 4f' ' R (s ; u, r 5 1 V' 1 r '; .,
� 3 < Cit of Tigard APR 2 8 2010 DatcBed Pcnnit No: . : l e ,' - CA!t
" 13125 SW HHiall Btvd,. Tigard, OR 97223
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. Plan ltevie Other I'ertntt
_ Phone: 503.639.4171 Fax: 503,598,196(CI OF TIGARD Uak/r3x:
I> �°lrt) I n te rn e t : w w . 50d -or. 3.639.4175 D ILead /13 !��' El See Page 2 for
Internet: www.ti and -0r. Ov BUILDING DIVISION
g g Notified /Method: Supplemental Information
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❑ New construction El Addition /altcratinn /rcpla ement p fees" arc based on the value of the work
performed. e the value (rounded to the nearest dollar) of all
❑ Demolition
ry f v ❑ Other: g Value: mechanical materials, equipment, labor. overhead, and • *fit.
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For special information use checklist. .
❑ Multi ❑ Master builder ❑ Other: cs
Description Qty. Ea. Tout!
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' V.•! -O (1 i,, ,.; M . ,,F O rl. nl (r . IT r,f; l' fS {t3a Heating/cooling
41 ,. �..
Job sitc address: 15622 SW 76 AVENUE Air conditioning
_ (requires site plan showing placement) 1 46,75 46.75
City/State/ZIP: TIGARD OR 97224 Furnace 100,000 BTU (ducisNents) 1 _ 46.75 46.75
Furnace 100,000+ BTU (ductvvents) 54.91
Suite/bldg. /apt, no.: Project name: #28768 Heat pump 61.06
Cross street/directions to job site: Duct work . 1 23.32 23.32
Hydronic hot water system I 23.32 _
Residential boiler (radiator or
h droiuc 23.32
Unit f l . i - (fuel-type, not electric). ■
mar -wall. p - duct, sususpended, etc. 46.75
Subdivision: Lot no.. Flue/vent for an of above 23.32
. _ Other: 23.32 -
Tax map /parcel no.: Other fuel appliances
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1.1.0Ab, v1'd.,4�i�,l,' � , tit. Lt . : V- ) d 1.4 54.vrV. }vl /'lrCr��"r�-0� �u.'
Ga Water heater 23.32
s fir lace 33.39
PUSH/PULL GAS FURNACE _ _ Flue vent for water heater or gas
INSTALL AC fireplace 1 23.32 23 -32
Log lighter (gas) 23.32
VENT WATER HEATER Wood/.ellet stove 33.39
DUCTWORK Wood fi - lace /insert 23.32
�, 1 - / fR �,,` , � �1,,, ( 1 U IP 1, "r { , '� n 'p "`( :'} ( 6 "... ( JdJr i.( hi�(t r 4' - Clzimnev /lines• /ffue'velit 23.32
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Name: STEVE AND ANDREA NIELSON Environmental exhaust and ventilation
Address: 15622 SW 76 AVENUE Range hood /other kitchen
d
A dr e --. --- _ equipment 33.39
City /State/ZIP: TIGARD OR 97224 Clothes dryer exhaust 33.39
Single-duct exhaust (bathrooms,
Phone: (503)670 - 8234 Fax: ( ) toilet compartments utili rooms 23.32
r wn� r r n, E4 , •'"r •7 r , r r 1 c , r. 1 r t � , i .. °� 'Y1. ° y r yr , 1.41: 2
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Other: 23.32
Business name: ANCTIL HEATING AND COOLING Fuel piping
Contact name: CHRISTINE BARTON 514.15 for first four: 54.03 for each additional
Address: 4320 N WILLIAMS AVENUE Furnace, etc.
- - -• --- Gas heat pump
City/State/2,1P: TIGARD, OR 97224 Wall/suspended/unit heater
Phone: (503) 670 -8234 Fax: : ( ) water heater
Fireplace
E-mail: INSTALL @ANCTILHVAC COM
.
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Business name: ANCTIL HEATING AND COOLING Clothes dryer (gas)
Other;
Address: SAME AS ABOVE °,� ., '',1 dYrl °i�Csi + 1 4'n r ' r 1+ F r ,i ^t ,.
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City /State /ZIP: Subtotal 1 140.14
Minimum permit fee (590.00)
,‘ `L rC: ( ) Fax: ( ) Plan review (25% of pennit fee)
' CCH I,c.: $ permit $97 State Surcharge (12 °/o of peit fee) 16782
TOTAL PERM 1'1' FEE l 15696
Authorized signature! Tins permlt application exiitres it a permit is not obtained within 180
flays after it has been accepted as complete.
1 Print Maine.: CHRISTINE BARTON ! Date: 4/28/10 " 1'ee methodology set by Tri- County fluilaiul. I ndustry Service Board
I. Avildiaa Penn nn.Nl1-<' - .4 ,n.tAp' ICM) I '09 4 .10. 10171' (I I'0?
Id Wd00:ZI OTOE 8Z 'add ZZLSZSZ 20S : '0N dNOHd 6u11001 8 6utgp lIlONH : WOdd
FROM : ANCTIL Heating & Cooling PHONE NO. : 503 2825722 Apr. 28 2010 1201PM P2
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City of Tigard
Building Division
13125 SW flail Blvd., Tigard, OR 97223
; `tl�' Phone: 503.639.4171 Fax 503.598.1960
� +' : /.. Inspection Line: 503.639.4175
City of Tigard Internet: www.ci.tigard.or.us
PAYMENT AUTHORIZATION FORM
Permit No. (if available):
Job Site Address:
Project Name:
Credit Card Information: Ma x i mum transaction amount is limited to $1,000.00.
Visa or MC No.: L/ . 1po 3Wf � (_
Expiration Date: ja-i 1 .
Cardholder Name (on card): --/ nAji..1, j j
-
Contact Phone No.: .'b3 - "le l — off _
Address for this card is: 1 e O L Hi3 LQyK", t 0 e...D. 7,
Zip code for this card is: 1 -a1'
Electrical Trust Account Information: For electrical permit applications only_
• Trust Account (CCB) No.:
Contractor Business Name:
Contact Phone No.:
X hereby give the City of Tigard permission t• • ay for the above referenced
permit with the credit card or electrical ust ac aunt number given.
Authorized Signa . � r
Name Printed: i ., c) L-- li
Date:
.Please fax this completed and signed form to 503.598.1960.
This form will be destroyed after your payment has been processed.
is 1Buildiihaorrns \PAvrtleitlA >al A r dd i n n
Sd WdEO:ET 010E 8E 'add EELSE8E 20S : '0N 3N0Hd 6ut Io00 2 6utI-E H 1 I10Nd : Woad •