Permit 1 1 4 e ° Community Developme
Request for Permit Action E�
Tlcnlzl� 9
npR 29 2010
TO: CITY OF TIGARD OIr( OF TIGARD
Building Division Services Coordinator BUILDING DIVISION
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 0 City Staff
(check one)
REFUND OR Name: 1
INVOICE TO: (Business or Individual) t 1 I/�
Mailing Address: !l/��� /'T
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ OVE CONTRACTOR FROM PERMIT (do not cancel permit).
\Pe t #: C- AO 10— 001
0 Site Address or Parcel #: 750 1 act) - 0 H2TP-IQ uTFf- R
(b Project Name: LLD. tJ (DEL/
t of Subdivision Name: Lot #:
EXPLANATION: 1./..(4 1,3 , 13 Co F-t A L-e r , i3 D f .0 VI E. if 2
t. i. `LL-SO 0.
Signature: C (&Wlti.Ck . Date: q /,9 /,'�
Print Name: 1 -.Ib e P a i-4 S k
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
Rte to Sys Admin: Date y $40 /4 Rte to Bldg Admin: Date /p /S /v By
Refund Processed: Date /V / By Invoice Processed: Date By
Permit Canceled: Date YfrQ//p Byjg Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \ Building \ Forms \RegPermitAction.doc Rev 07 /26/07
Mechanical Permit Application 1. ( r F 1( �.: I S E O N1.1
• 'ti p �. ' � I R. • _. -
City of Tigard "' Permit No.: -p.. 9
13125 SW Hall Blvd., Tigard, 0 7.23` JD (I �✓
C Phone: 503.639.4171 Fax: 503.59 W 1 . p e gy eW Other Permit: /e ms C 0 _��
T 1 G A R D Inspection Line: 503.639.4175 A r I( !.+ 9 2010 %%! Date Ready/By: Jens HI See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
CITY OF IIGAFI
TyFBUIVIIIiraiDIVISIO '•` COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
❑ New construction Addition/alteration/replacement Mechanical permit fees* are based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $ Co DPV
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 1- and 2- family dwelling :9'Commercial /industrial ❑ Accessory building
For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description 1 Qty. 1 Ea. 1 Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address:'? O l Sw 0 cif i-Arr i o \1! g A Air conditioning or heat pump
l plan site lan showin placement) 14.00
City/State/ZIP: 'f• (A 1'11'-)----5 Fumace 100,000 BTU (ducts/vents) 14.00
t ` Fumace 100,000+ BTU (ducts/vents) 17.90
Suite/bldg. /apt. no.: Project name: 1 V nW :1 \ Gas heat pump 14.00
Cross street/directions to job site: Duct work 10.00
Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 14.00
Flue/vent for any of above 6.80
Subdivision: Lot no.:
Other: 10.00
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
^ ' q 1" p I n Gas fireplace 10.00
,(
1, N UV VA 'V of �w ( l 1 ' 1 �(V l �� -c('(, V} Flue vent for water heater or gas
' e fireplace 10.00
p VIJ v\ V.Ok 1/ /i, W j V kk ; A. �� 1 14.k/ ti V,61:1-e' Log lighter (gas) 10.00
I W(--k- a' j(ki V S Wood/pellet stove 10.00
Wood fireplace/insert 10.00
Chimney/liner /flue/vent 10.00
❑ PROPERTY OWNER I ❑ TENANT Other: _ 10.00
Name: Environmental exhaust and ventilation
Range hood/other kitchen
Address: equipment 10.00
City /State/ZIP: Clothes dryer exhaust 10.00
Single -duct exhaust (bathrooms,
Phone: ( ) Fax: ( ) toilet compartments, utility rooms) 6.80
❑ APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 10.00
Other: 10.00
Business name: V Pi tTA,L Fuel piping
Contact name: 55.40 for first four; $1.00 for each additional
v 1 n , Furnace, etc.
Address: (7 -3 - 1 N �t(t \A 6) ail
Gas heat pump
City/ State/ZIP: t (`W 0�,� l 0 _ 1 Wall/suspended/unit heater
i ) -� \o'. t9---1S--- Water heater
Phone: (� �� Fax: : (�
f� GA NA � �1 Fireplace
E -mail: ,',o V `� l ��rj , VI G V `( lc 0 a W V \P Range
CONfRAtTOR Barbecue
1 \) Clothes dryer (gas)
Business name: t V P L; U Other:
Address: 10 C / ° )' MECHANICAL PERMIT FEES*
City /State /ZIP: �/ "�/ Subtotal
Minimum permit fee ($72.50)
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB lic.: Q ' G1�1 State surcharge (12% of permit fee)
411 TOTAL PERMIT FEE
This permit application expires tilt permit is not obtained within 180
Authorized signature: / / days after it has been accepted as complete.
Print name: \ 4 0� t A) Date: y /-j.� / ( D ` Fee methodology set by Tri-County Building Industry Service Board
11Building \Perm its\MEC- Permit 440-4617T(1I/00002/CO,WWEB)