Permit CITY OF TIGARD MECHANICAL PERMIT
` COMMUNITY DEVELOPMENT Permit #: MEC2010 -00281
Date Issued: 06/18/2010
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S104DB00300
Jurisdiction: Tigard
Site address: 13159 SW BROADMOOR PL
Subdivision: AMESBURY HEIGHTS Lot: 3
Project: Tsuruta
Project Description: Install wood fireplace
Owner: FEES
TSURUTA, [SAO Description Date Amount
23 HILLSIDE Wood Fireplace /Insert 06/18/2010 $23.32
EAST HANOVER, NJ 07936 12% State Surcharge - Mechanical 06/18/2010 $10.80
PHONE: Minimum Fee Adjustment - Mechanical 06/18/2010 $66.68
Contractor:
LUDEMANS INC
12675 SW BEAVERDAM RD
BEAVERTON, OR 97005
PHONE: 503 - 646 -6409
FAX: 503 - 646 -8034
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Fuel
Fuel Types: Solid Fuel
Gas Pressue:
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 -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: Permittee Signature: Dr - JAG% &I-77
CaII 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.
111 q
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Ludeman's, Inc. DATE: 10/22/2010
12675 SW Beaverdam Rd.
Beaverton, OR 97005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 178374 Case #: MEC2010 -00281
Date: 6/18/2010 Address /Parcel: 13159 SW Broadmoor P1.
Pay Method: CreditCard Project Name: Tsuruta
EXPLANATION: /'e=/2. ' . C-�r S �Z °, y� , , t lfnic c t�.e met A
d E- t.f "ra J `7 , A2" i / .
REFUND INFORMATION:
Fee. Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Mechanical Permit 2300000 -43102 $72.00
12% State Surcharge 1003100 -24001 8.64
TOTAL REFUND: $80.64
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
6/
If under $25,500 Department Manager %
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: 1 it/Z-Vie lc By: 1 f
I: \Building \Refunds \RefundRequest.doc a 09/01/2010
07/11/2005 13:45 FAX 5035981960 CITY OF TIGARD Liyuux
•
EIVED
Building Division AU S 3 1 7010
: � Applicant Request for Permit Action C OF TIGARD
City of Tigard , _ BUILDING DIVISION
TO: CITY 01? TIGARD, BUILDING OFFICIAL
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.63 9.4171 Fax: 503.598.1960
t Name: �C Y�r� �n . (Jo r' i 4c ,[�r - r)
FRONT: Applicant S
Mailing Address: /d69 2 f J ° 17rrs CICzn_
City /State/Zip: ....&,-...:-..., c ___e3/______2.2_e___
Phone No.: d3 6.05/6 lo 9 ,
Fax No.: __�2 �,.3— C- / - , -3 .
PLEASE TAKE ACTION CHECKED (1) FOR TEE FOLLOWING PERMIT:
❑ CANCEL PERMIT APPLICATION. .
0 REFUND PERMIT PEES_
Permit No.: i'YI 5C d O /C.`. 2Zi a F / _
Type of Permit: /7/cc `,a /9 ,cq
Site Address: 4345 9 ..cJ 13, ek oar P
Subdivision: 411, 26. . cf,
Lot No.:
* r of /e / c//7
EXPLANATION: U�S �pM � -- /� • / � �• s c
Ae 7 2 • - ki E d Ao /a - oo. .36
1
C-- - ' 9g,,Z._
S ignature: Date: - o 7 7/d
Print Name: a� >' Wei , t .
(,--
Route to Admin.: _Date: rd Zf, /O By: _
Permit Canceled: Date: /Q f 2,,/ v BY=
Refuel Processed: 1 Date: ii Z` t, B
Cashier Receipt: Date: /,F ed #: / 73 7/ Alit 5 /d o .- 0
Pa ►meat T A. -: G _ Per: .
i:18ui1dirOcK Al esPamhAc ion 09- 27 -04.dec
Z00/1 'd 9680# sNUW30n100 -INo V E0899179 EOS Zb:ll OLOZ /OE/80
• City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
tn
Ittigottu
October 29, 2010 I I
Ludeman's Inc.
12675 SW Beaverdam Rd.
Beaverton, OR 97005
Attn: Joni Hacker
Re: Permit No. MEC2010 -00281
Dear Ms. Hacker:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following.
Site Address: 13159 SW Broadmoor Pl.
Project Name: Tsuruta
Job No.:
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $80.64.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4.-17 4 . 1 "
7 '
Dianna Howse
Building Division Services Supervisor
Enc.
1: \ Building \ Refunds \ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
Er City of Tigard
TARO Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Ludeman's, Inc. DATE: 10/22/2010
12675 SW Beaverdam Rd.
Beaverton, OR 97005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 178374 Case #: MEC2010 -00281
Date: 6/18/2010 Address /Parcel: 13159 SW Broadmoor Pl.
Pay Method: CreditCard Project Name: Tsuruta
EXPLANATION: 0°12. . .A.z.es T'. S ( T6'r3
E i .4 A Pc `a of Tx/v/7 ,.: s .
REFUND. INFORMATION:
Fee. Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Mechanical Permit 2300000 -43102 $72.00
12% State Surcharge 1003100 -24001 8.64
TOTAL REFUND: $80.64
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
If under $25,500 Department Manager - 4 ) / %G �� Av
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: 1 Date: 1 /C /L9 //C By: 1 f i
I: \Building \Refunds \RefundRequest.doc x 09/01/2010
,
• CITY OF TIGARD RECEIPT
a
. g . • . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
0216:;
Receipt Number: 178374 - 06/18/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2010 -00281 Wood Fireplace /Insert 2300000 -43102 $23.32
MEC2010 -00281 12% State Surcharge - Mechanical 1003100 -24001 $10.80
MEC2010 -00281 Minimum Fee Adjustment - Mechanical 2300000 -43102 $66.68
Total: $100.80
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 493989 DHOWSE 06/18/2010 $100.80
Payor: Joan Hacker, Ludemans
Total Payments: $100.80
Balance Due: $0.00
•
Page 1 of 1
CITY OF TIGARD RECEIPT
g . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD r
Receipt Number: 180210 - 10/29/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2010 -00281 $ -80.64
Total: $ -80.64
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 493989 DHOWSE 10/29/2010 $ -80.64
Payor: Joan Hacker, Ludeman's, Inc.
Total Payments: $ -80.64
Balance Due: $80.64
Page 1 of 1
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Plan Review
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+" ° '.- -- Inspection Line: 503- 639.4175 D ate [read /g . tf :
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144 Internet www.tigard or CITY OF j IGARD Not fied/Merhod, 716- Supplemental Information
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' 0 New construction 11 Addition /alteration/replaccmcnt Mechanical permit fees" arc based on the value tithe work
performed- Indicate the value (rounded to the nearest dollar) of all
0 Demolition 0 Other: mechanical materials. -• • - t, labor, overhead. and • •fit:
r YP „ i 1 ,z 't rm,/:� a .sr r r x : .4 ,. 7'V r a ri a51, tR Value: $
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t,, 1- and 2-family dwelling 0Commercial/industrial ❑ Accessory building
k t rr, +ar �wx r ..tear r >r, �� �A
For special information use checklist.
0 Multi- family t YY�yy 0 Master builder 0 Other: n , Description I Qty. r Ea_ 1 Total
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ob site address: /3/5- �} // Air conditioning
l
/ � YG��Y/y)Oar �Z ui,eRSitc •lvxs ' . : .laoement) 46-75
City /State/ZIP: '7-/ GG A q 7 c. Furnace 100,000 BTU (ducts/vats) Mil 46 - NM
Furnace 100,000+ BTU (ducts/gents) 54.91
Suite/bldg./apt no.: Project name: / 54. Az 7 — Heat . ,• 61 -06
Cross street/directions to job site: y Duct work 23.32
' H . Ionic hot water s M
Residential boiler (radiator or
• • h •ronic III 23.32
. — Unit heaters (fuel -type, not electric), Ill
in -wall, in -duct, su , ded, etc. 46.75 .
—" Flue/vent for any of above 23.32
Subdivision: J Lot no.: Other: 23.32
Tax in no.: Other fuel appliances
'` aT 0 : ,f 4:Fi ;Fit y °r pr vt �}' 1 r -74';: 1 , , 7 r �;,,S, 4«�tY Tt 0 i �,, el ,„ 7 ,,, 17,. 42 t
.ki�',$f,,r' theater 23 -32
C , v , v r .d ,.:. r.2i.rs`...,.... , tj .L ...a Water
Wu,.v . s..., 0 . 1 . ...,a,.. «l e.. ..'. M hk. ..r:arJx. a. .an:L:rr.. . n .,, i5.r,. Gas fireplace 33.39
-; s 7 ?�l c -f_,/'O z J / . / / /Q ` Flue vent for water heater or gas
• lace 23.32
Log lighter (gas) - 2132
W.... - llet stove 3339
'� Wood fireplace/insert 23 -32 e iggla
, Y' , "2 1 ''7 f ( ? eM Td" '} .1 jW41 y � rA �Y�, r , / l y
1 �..himn /liner /fl ue/vent MI
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Name: 77S.Q 7 4. '� ._ Environmental exhaust and ventilation _
Range hood/other latchen
Address: 1 . 3 / . : 5 ' 9 o S G � J /,7 ae7, -e P' ' . equipment 33 -39
City/Statc/ZIP: / /6 9fJ Q, 7c3 3 Clothes . , exhaust 3339 NM
Singt wimp exhaust (bathrooms, jy rooms)
Phone: (9 ) -2.- �Z,5 // Fax: ( ) toilet compartments, utiliy rooms) 23 -32 III
syyi r t r" +' W;' M r i' c r , i a � t .1{ r N P r � . ; � g ( t e4.5 0 :ri� ' t:5\ r .. +m r, ,y rr , ^4-'40V ' ((' 3 � At Attic/crawl, " fans 23.32
5 '.14** ari ':. :'�J. : %`i' m dri LJ., u'"+ .∎1'.1tii4h2 eCJ A. ..4.m.>w fu�•4',v` Glen 4w .- .,1iv-,:I ».M»z4.' Other: �� �
Busittass name !/l /7 _ Nei piping —
Contact name: JO s�,9� & $14.15 for first fear, $4.03 for each additional
/ Fu rnace, etc- __ ME
Address: / oZCo 7S w J.:3 �'C�[if /C�S�m /C , �
City /State/ZIP: /3 vim ✓ -4.c h Q 2 n 7 GZ 5 Wa]Us ... . ed/tmit heater
Water heater _ ��
Phone: (503 ) / I Fax:: ( — ) Fireplace � E J dh / h > �4f c 4 if 5 (L' °/``? Range �
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Clothes drier (e) Business name: 4 214/,'? _T Other
r if?haTg rt a r , M';' i,2 w 1 r r w -� f ti � ,�k FF::' � ' pin
Address: -_ 0 ?' "7 ,, 41
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Subtotal - V6,Cs°V
CityIState/ZlP: _ Minimum permit fee ($90.00) _ O)
Phone: ( ) v e<5 ax: ( ) ..
Plan review (25% of permit fee)
State surcharge (12% of permit fee) /O•
,d,� CCB lie.: / / / _ _ TOTAL PERMIT FEE /Cd . , 0
v (�� r s,,44', This permit application if a permit 4 not obtained within 180
Authorized signature: days after it t has has b b een accepted as rotnpIcte•
�,� % O / Date: - .. Mil ' Fee methodology set by Tri-County Buildin8 indusa' Service �M
I Print name: tS» / 5�=1 /`
€OO /Z00'd 2190# SNV11301110 -IN01r VE0899179 COg Zt+:9l OIOZ /!.l /90