Permit 1 w „ CITY OF TIGARD MECHANICAL PERMIT
111 COMMUNITY DEVELOPMENT Permit #: MEC2011 -00036
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/20/2011
Parcel: 1S135CD04700
Jurisdiction: Tigard
Site address: 11865 SW 95TH AVE
Project: Good Subdivision: BOETCHERS ADDITION Lot: 8
Project Description: Wood stove installation.
Contractor: OWNER Owner: GOOD, JAMES JR &
GOOD, JULIA
11865 SW 95TH AVE
TIGARD, OR 97223
PHONE PHONE:
FAX:
FEES
Specifics: Description Date Amount
Wood /Pellet Stove 01/20/2011 $33.39
Type of Use: SF 12% State Surcharge - Mechanical 01/20/2011 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 01/20/2011 $56.61
Occupancy Grp:
Stories:
Fuel
Fuel Types:
Gas Pressure:
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 -0090. You may obtain . sy of t ,- rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.
. / Issued By: � . . Permittee Signature:
ASV
Call 503.63•.• by 7:00 a.m. for the next available ins • • ction date.
This permit card shall be kept in a conspicuous place on the job si until completion of the project.
Approved plans are required on the job site at the • e of each inspection.
Mechanical Permit Application i FOR OFFICE USE ONLY
City of Tigard DReceiate /Byved : Permit No.: = i'_
° 13125 SW Hall Blvd., Tigard, OR 97223 � V
C ' Phone: 503.718.2439 Fax: 503.598.1%0 j Plan Review
D ate / Review Other Permit:
T I G A R D Inspection Line: 503.639 �� + Date Ready/By: luris ® See Page 2 for
Internet: www.tigard - or.gov L %\\ Notified/Method: �y Supplemental Information
b L r..Yll
TYPE OF WORK 3n. erAG '` 014 COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
a4 c �1 1s Mechanical permit fees* are based on the value of the work
❑ New construction ❑ Addition/alteration/ a iv t v performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demol ID Other: 8 09
CATEGORY OF CONSTRUCTION
mechanical materials, equipment, labor, overhead, and profit.
Value: $
RESIDENTIAL EQUIPMENT /SYSTEMS'FEES*
Lit 1 -and 2- family dwelling ❑Commercial /industrial ❑Accessory building For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: / ( 9 ( c (.,0 q L., (requires site plan showing placement) 46.75
City/State/ZIP: z-3 Furnace 100,000 BTU (ducts /vents) 46.75
Y �� DI, 7 t Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: / Project name: 6r Qb Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
��f/ '_l Gas fireplace 33.39
(/L /Uc ,S j� / /V �` ` Z7 , --L Flue vent for water heater or gas
fireplace _ 23.32
Log lighter (gas) 23.32
Wood /pellet stove ( 33.39 33 ,37 Wood fireplace /insert 23.32 //
❑ PROPERTY OWNER ❑ TENANT Chimney/liner/flue/vent 23.32
Other: 23.32
Name: `-i R - 4'/45 67 pen Environmental exhaust and ventilation:
Address: /7 6 5 50 /fu--e -- Range hood/other kitchen
equipment 33.39
City/State /ZIP: / ��,-,/2JD b g'7 2-2.3 Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: /
c 5�D, 1 5 -, d 8 6 8 Fax: ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Other: 23.32
Business name: � MQ G.
x %$ 06 ( 1114_ _ Fuel piping:
Contact name: $14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater
Fireplace
E -mail:
Range
CONTRACTOR Barbecue
c' ,— Clothes dryer (gas)
Business name:
V V Other:
Address: MECHANICAL PERMIT FEES*
Subtotal `
City /State /ZIP: Minimum permit fee ($90.00) 7.?'"
)
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB lie.: State surcharge (12% of permit fee) / 0
TOTAL PERMIT FEE / do
This permit application expires if a permit is not ob fined within 180
Authorized signatur-: days after it has been accepted as complete.
Print name: C 1 - es c9 D Date: �, D l
f / * Fee methodology set by Tri- County Building Industry Service Board
�
I. Building 'PermitsV�C- PermitApp.doc 09/09/10 440 -4617T (11/0 OM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi- Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and
$3.07 for each additional $100.00 or
fraction thereof, to and including
$5,000.00.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
$2.81 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
I:\BuildingWermits\MEC- PermitApp.doc 09/09/10 2
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.
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.
Un e-5 Goe)
Print Name of Permit Applicant /; 1
� �
• • .ture of PermitAppli :nt Dat
Permit #: AIIC 2d 0003&
Address: , .'; , : r
Issued by: ,, . Date: frik
This Copy for Permit Offices