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Permit CITY OF TIGARD MECHANICAL PERMIT • COMMUNITY DEVELOPMENT Permit #: MEC2009 -00482 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/14/2009 IIGARD Parcel: 1S 136DB02000 Jurisdiction: Tigard Site address: 10940 SW 74TH AVE Subdivision: Lot: 0 Project: Nelson Project Description: Replace oil furnace with gas furnace. Owner: FEES NELSON, ROBERT L SHIRLEY Description Date Amount 12316 NW CORNELL RD Furnaces < 100K BTU 09/14/2009 $14.00 PORTLAND, OR 97229 Fuel Piping 09/14/2009 $5.40 PHONE: 12% State Surcharge - Mechanical 09/14/2009 $8.70 Minimum Fee Adjustment - Mechanical 09/14/2009 $53.10 Contractor: OWNER PHONE: FAX: 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 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 OU calling 503.246.6699 or 1.800.332.2344. 011, Issued By: Permittee Signature: / ' I 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. Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.055 (4)) 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. S i r 14_4y e,1 SO Print Name of Permit / Applicant i) id ) o ignature of P e it plicant Date Permit #: 0 — COL( g O f o t O �( c3tA 4 ' t�4- Address: /`����u��i!!�s,�, ihTlr 1 •O a -� 02 9-1 2;93 .: E Issued by:' Date: 901(0g This Copy for Permit Offices RECEIVED , Mechanical Permit Applica °` -, :. FOR OFFICE.11SE ONLY ' ' - ' - E Iew C / Iff /A A permit ref / � 0 5/ lii ' ... ] 31SW Ha Blvd, Tigard, OR 9722 10 200 D - ,- ©�P (/V Ja .1 0 . P 503.639.4171 Fax: 503.59 196D, Other Permit: Hi OF TIGARD Date/By: Inspection Line: 503.639.4175 y Ti GARD p Date ReadylBy: Juris: ® See Page 2 for Internet: www.tigard or.gov BUILDING DIVISION Notified/Method: Supplemental Information G'„` V - E( `4 ' `Pei - a a..,.:..�,k e..,,<:-fer , e a ;" '''f� Z<TO <',,5�'E S ,.-ail - ;'"i v * :., m:-> .afdliq. , .. ..'3 „ -,v ; :z f " . , .,, ` � , f � YPaE OF ,A®R.. r4' < ' R% � r s I x RIK , „COMMERGIAI ,,,,, ` S, I DU,LI US C iiE I STc Mechanical permit fees* are based on the value of the work ❑ New construction Addition /alteration /replacement performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition Other: mechanical materials, equipment, labor, overhead, and profit. , % °' . ` F CASTEGOR'Y ,OFrCOs JCTTON' � ,kreh Value $ ... ...... ��. ...3 1 . %. � IDE, e,e TE MS E ES* tea « ® 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist. ❑ Multi- family ❑ Master builder ❑ Other: Description Qty. Ea. Total #.t . s:,. ` JOB�STIIE INFOR : I f6:165CA 70011 z _ . 4 re y Heating /cooling Job site address: 1 U 6 1 Li v W y f it Air conditioning or heat pump J 7 (requires site plan showing placement) 14.00 City /State /ZIP: Fumaee 100,000 BTU (ducts /vents) / 14.00 N 1 �� Furnace 100,000+ BTU (ducts /vents) 17.90 I Suite /bldg. /apt. no.: Project name: Gas heat pump 14.00 Cross streeUdirections to job site: S 4 ■--R, j --).� ■ , Duct work 10.00 Hydronic hot water system 14.00 1 of e(A- -(y prod i'14 i2-( Residential boiler (radiator or I hydronic) 14.00 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 14.00 Subdivision: Lot no.: Flue /vent for any of above / 6.80 Other: 10.00 Tax map /parcel no.: Other fuel appliances �" ' .N DFsSCRIPPPiTIC1N OF iVat 4: , Water heater 1 0.00 ..a,. , . =.w., r Gas fireplace 10.00 oerPL4-Lv 0 /L.. / -6` G(1 / 77f Flue vent for water heater or gas ru fireplace 10.00 t�- Log lighter (gas) 10.00 Wood /pellet stove 10.00 Wood fireplace /insert 10.00 ;- ; > " a E.T. 2`OPERTY. 410WNER , . , 4 ray. : ". .2 , . 5 „ � ', oth 10.00 10.00 Name: 7h co 1 V v /(,�.,, Environmental exhaust and ventilation Range hood /other kitchen Address: 2..: g ) (0 1/ Iv c 0 r ' n e - (I k'• r equipment 10.00 City /State /ZIP: l' + ea , � A c) 6 ) 7 229 Clothes dryer exhaust 10.00 V() / J� p Single -duct exhaust (bathrooms, Phone.Zig ) 6 vi, S�9y Y.5 779 , toilet compartments, utility rooms) 6.80 APPLTCANgT� / � r' ` ` s U®NTA ' T PERSO ;= 4 Attic /crawlspace fans 10.00 .,.4..-4` ,§ »z-r... x v.,,,,L«4,,,,4,, _:, we` '. r..�� e.v..� arr� = .�...,�"w-,1,„ . ,,,, _...,,,,,, ti,'...,a .., ,,t, .',aa "a -� .. Business name: I Other: 10.00 Fuel piping Contact name: $5.40 for first four; $1.00 for each additional Address: Furnace, etc. Gas heat pump City /State /ZIP: Wall /suspended /unit heater Phone: ( ) Fax:: ( ) Water heater Fireplace E -mail: Range .. � �, t a 3 y �r , � X . t + '`t a ` . ' " � k x 44w, a , nC O NTRACTOR £. a3, .,. 1 6 g n r saa , k t, Barbecue ��6 Clothes dryer (gas) Business name: O Other: Address: y M P R IiT ,FEES *', , City /State /ZIP: Subtotal Minimum permit fee ($72.50) 72, 5'e Phone: ( ) Fax: ( ) Plan review (25% of permit fee) CCB lic.: �j� State surcharge (12% of permit fee) , - ' " --/- / Y ` /; : p-, TOTAL PERMIT FEE ' ,U This permit application expires if a permit is not obtained within 180 Authorized signature:, ' t days after it has been accepted as complete. Print name: S 1t te✓ / (L �A 5Q h Date: �'f )`� 1 0 Fee methodology set by Tri- County Building Industry Service Board • \ \ M 1:\ Building Permits EC- Permit App. doc 01/19/07 440 -4617T (I I /02 /COM/WEB) • Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial Fee Schedule: 0, al V luataon 4Perin;<t - $1.00 to $2,000.00 Minimum fee $72.50 $2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,001.00 to $10,000.00 $141.50 for the first $5,000.00 and $1.80 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,001.00 to $50,000.00 $231.50 for the first $10,000.00 and $1.35 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and $1.25 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $1,396.50 for the first $100,000.00 and $1.10 for each additional $100.00 or fraction thereof Note: All new commercial buildings require 2 sets of plans. 1: \Building \Permits \MEC- PermitApp.doc 01/19/07 2