Permit CITY OF TIGARD MECHANICAL PERMIT
2 COMMUNITY DEVELOPMENT Permit #: MEC2011 -00484
Date Issued: 11/01/2011
TEGAR.D 13125 SW Hall Blvd , Tigard OR 97223 503 718.2439 Parcel: 2S103AD06700
Jurisdiction: Tigard
Site address: 12775 SW 111TH PL
Project: LEMIEUX Subdivision: WILDERNESS Lot: 13
Project Description: Gas fireplace insert and fuel piping for fireplace, range and barbecue.
Contractor: NW GAS LINES Owner: LEMIEUX, DEREK B & HEIDI A
16731 NE WASCO ST 12775 SW 111TH PL
PORTLAND, OR 97230 TIGARD, OR 97223
PHONE: 503 - 256 -2436 PHONE
FAX: 503 - 256 -2245
FEES
Specifics: Description Date Amount
Gas Fireplace 11/01/2011 $33 39
Type of Use: SF Range Hood /Other Kitchen 11/01/2011 $33 39
Class of Work: ALT Type of Const: Fuel Piping 11/01/2011 $14 15
Occupancy Grp: Mechanical Permit - RES 11/01/2011 $9 07
Stories: 12% State Surcharge - Mechanical 11/01/2011 $10 80
Fuel
Fuel Types: Natural Gas
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 a copy of the rules
or direct questions to OUNC by calling 503 232.1987 or 1 800 332.2344
Issued By: i • Permittee Signature: _ 41r1 / 1
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
'1
Oct 28 11 01:12p Tony Young 503- 256 -2245 p.2
Mechanical Permit Application FOR OFFICE USE "ONLY
City of Tial'd �k Received
III `J g °i y nt No.
■ 13125 SW Hall Blvd., Tigard, OR 97.28
Date/BY 0 MAIM I Pe ^"" _:L �� 1 1 .//
�� Plan Review
Phone: 503.718.2439 Fax: 503. '8A1960 �O c/gy. Other Penni
Inspection Line' 503 639 4175 . r
TIGARD k VP .. V 1\'V) Date Ready/By: luns H See Page 2 for
Internet: w and -ar. ov vevy.ti
g 1§...., 4V '� ; Notified /\9cthod: '� - �� Supplemental Information
TYPE OF WORK, d V' COMMERCIAL FEE' SCHEDULE — USE CHECKLIST
ws a �,� Mechanical permit fees' are based on the value of the work
❑ New construction ddition /alteralioru:rt:plpeement performed Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit.
Value: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
I- and 2- family dwelling ❑ Commerciallindnstrial ❑ Accessory building For special information use checklist
Multi-family ❑Master builder ❑Other: Description I Qty. I Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: . -77 —, S � . /0/ (requires site plan showing placement) 46.75
v // Furnace 100,000 BTU (ducts/vents) 46.75
City/State/ZIP:
d! f �r p; Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg./apt. no.: Project name: / :2 P� // Heat pump
/! (requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
Flvdronic hot water system 23.32
Residential boiler (radiator or
hydronic) 2332
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc- _ 46.75
Subdivision Lot no.: Flue /vent for a of above 2332
Other: 23 32
Tax map /parcel no.: Other fuel appliances_'
DESCRIPTION OF WORK Water heater 23.32
� /' � ( �1�i f�/J /' Gas fireplace if 33.39 33 a3 9
`%, k`S/ ! e C /��v! r/ r " e1/ /7) Flue vent for water heater or gas
f
��� / - /z � gg 4. / /,-, ( // fireplace g �. /r(, Log lighter (pas) 23.32
23.32
�/ . f '� ,5"e7 Wood/pellet stove 33 39
Wood fireplace/insert 23 32
PROPERTY OWNER ❑ TENANT Chlmneyllinerlflue/vem 23.32
Other: 23.32
Name:
l . ( 0 Air � , /d/ 1�ni ' .r(�� Environmental exhaust and ventilation:
Range hood /other kitchen p
Address: / - C ) 1 ri equipment / 33.39 3 ') s3-I
City/State/ZIP: — � ( ii i /' J tti/ / •97 -3 Clothes dryer exhaust 33.39
1 Single -duct exhaust (bathrooms,
Phone: 673) 57 ,,l e7/,,,. Fax: ( ) toilet compartments, utility rooms) 23.32
o ❑ APPLICANT ❑ CONTACT PERSON Atiic /crawlspace fans 23.32
Other _ 23.32
Business name: ' 1J j , ,I ;/ . Fuel piping:
Contact name: 44 Furnace, ezi - r li(,e, y) 514.15 for first four, 54.03 for each additional
Address: Furnace, etc. //,l, ( y
CIty/State/ZIP: Gas heat pump
Wall/suspended/unit heater
Phone: (b3 )�,S4a —a 4, Fax:: ( 5D3 0256 — ,2ay5" _ Water heater
E -mail: y��%%� Fireplace
j1L jLd �r ` S 4,0 S/ 41 f Range / I
. / CONTRACTOR Barbecue
Business name: 1/i' �7/f (/r ,7C S Clothes dryer (gas)
l f /Y y1 / ! K�"'`� �� Other
Address.
(� MECHANICAL PERMIT FEES*
City /State2lP: , Subtotal t1?
Phone: ) F �J'� - )e ( (� Minimum permit fee (591100) / 0
( ( +1V7 ` JQ' / J Pl an review (25% of permit fee)
GCB tie.: /(5 vg f f State surcharge (12% of permit fee) yir,), nv
//��+r� /� / TOTAL PERMIT FEE b 6, 'D
Authorized signatureGLGG' r This permit appticatioa expires if a permit is not obtained within 180
644 days after It has been accepted as complete.
Print name: La ra yd -z Date: /� 8�j ( " Fee methodology set by Tn County Budding Industry Service Board
I.1Bni ing\PenniisUttEC- PermuAnp.doe 09109/1 440.4617T(11 102/COMAVEB1