Permit CITY OF TIGARD MECHANICAL PERMIT
:' .. 11 `'- COMMUNITY DEVELOPMENT Permit #: MEC2011 -00327
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/13/2011
Parcel: 2S103CB02000
Jurisdiction: Tigard
Site address: 12220 SW JAMES ST
Project: IVERSON Subdivision: Lot:
Project Description: Wood stove insert and liner.
Contractor: OWNER Owner: IVERSON, LARRY T & SANDRA L
12220 SW JAMES ST
TIGARD, OR 97223
PHONE: PHONE: 503 - 709 -3214
FAX:
FEES
Specifics: Description Date Amount
Wood Fireplace /Insert 07/13/2011 $23.32
Type of Use: SF Chimney /Liner /FlueNent 07/13/2011 $33.39
Class of Work: ALT Type of Const: 12% State Surcharge - Mechanical 07/13/2011 $10.80
Occupancy Grp: Minimum Fee Adjustment - Mechanical 07/13/2011 $33.29
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-se • 1 ou may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. /
Issued By: ..0.- j Permittee Signature: % J�l
Call 503.639.4175 by 7:00 a.m. for the next available inspecti
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.
Mechanical Permit Application OFFICE USE ONLY
Received
111 . City of Tigard ,D Date/By: 7 / /WPM No.: J ` „ii ;__-7
13125 SW Hall Blvd., Tigard, OR 4 . `'�\
LQ Date/By:
Review
Phone: 503.639.4171 Fax: 503.59:11 % Other Permit:
"1" 1 G n lR l7 Inspection Line: 503 0\'' Y � Q Date Ready/By: ® See Page 2 for
w
Internet: ww.tigard or.gov r\ � ® F �® \�� ®� Notified/Method: i Supplemental Information
TYPE OF WOR COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Y.+ - permit fees* are based on the value of the work
❑ New construction ❑ A ton/alteration /replacement performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
1 - and 2 family dwelling ❑ Commercial /industrial ❑ Accessory building
For special information use checklist.
❑ Multi - family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
a1 S 4 _ Air conditioning
fi res s ti plan Job site address: / n
� � I� � �. (9 p showing placement) (requires site Ian showin lacement 46.75
City/State /ZIP: 776 ®72/ , Ode 9 7 72-S Furnace 100,000 BTU (ducts/vents) 46.75
' i J Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: I Project name: • =is0� Heat pump 61.06
Cross street/directions to job site: / �j Duct work 23.32
/a % r K i-iu T A. �v z1(hr.:/< R eside n i hot water (radiator 23.32
Residential boiler radiator or
hydronic) 23.32
7 ( Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Flue /vent for any of above 23.32
Subdivision: 1 Lot no.:
Other: 23.32
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF 'WORK Water heater 23.32
Gas fireplace 33.39
�' f `
". (,l ,L L � A �� l :.-p-,7" Flue vent for water heater or gas
4 / a � p �� s � I JL S Log
fireplace 23.32
`j �/J� �l Log lighter (gas) 23.32
- jig Wood/pellet stove 33.39
� Wood fireplace /insert / 23.32
KPROP.ERTY OWNER I El TENANT
Chimney /liner /flue /vent 23.32
Other: 23.32
.--"" Name: 1 ,0'� / � - , , Environmental exhaust and ventilation
Address: /A A. 0 - .� Range hood /other kitchen
�- � // " equipment 33.39
City /State /ZIP: /9,,e - Clothes dryer exhaust 33.39
79q ` 2'21 103 / g�� t
Single-duct compartments, duct nts (bathrooms, rooms) s,
Ph o n e: ( Fax: ) toilet crtm utility ro 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Other: 23.32
Business name:
ALbT
Fuel piping
Contact name: $14.15 for first four; $4.03 for each additional
Furnace, etc.
Address:
Gas heat pump
City /State /ZIP: Wall /suspended/unit heater
Phone: ( ) I Fax:: ( ) Water heater
Fireplace
E -mail: Range
CONTRACTOR Barbecue
Business name: � _ . Clothes dryer (gas)
. n r,prhvgiwi pAwArf :�� Aliriz/��z'1t=A' A_., Gi
Other:
Address: j;;,a.��fM MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal
•
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) ea dd
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee) /0,, ec/
TOTAL PERMIT FEE fC.1 86
Authorized signa re" / /fir' This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Print name: i i,7 /��a Date: * Fee methodology set by Tri- County Building Industry Service Board
1:\ Building \ Permits \MEC- PermitApp .oc 10/01/09 440 -4617T (I l /02 /COM/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:\ Building \Permits\MEC- PermitApp.doc 10/01/09 2
r
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 , homeowner statement is true and accurate.
Z //6-/erc),J
Prin me of Permit Applicant
0,/ /
ignatur of Permit Applicant Date
Permit #: /
SGtl. »�.e s
Address: / 4 • 010 r ,�. •– ��������i�s .
e .> YE"•■r =, 'j
•
Issued by: g-7'; Date: / //J /�
This Copy for Permit Offices