Permit CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: MEC2011 -00365
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/19/2011
Parcel: 25111 DA14200
Jurisdiction: Tigard
Site address: 15590 SW EMPIRE TER
Project: WAKED Subdivision: Lot:
Project Description: Vent fan for roaster in garage.
Contractor: OWNER Owner: WAKED, NIMER & AMELL
15590 SW EMPIRE TER
TIGARD, OR 97224
PHONE
PHONE:
FAX:
FEES
Specifics: Description Date Amount
Single Duct Exhaust (Bathrooms, Toilet, 08/19/2011 $23.32
Type of Use: SF Utility Rooms)
Class of Work: ALT Type of Const: 12% State Surcharge- Mechanical 08/19/2011 $10.80
Occupancy Grp: Minimum Fee Adjustment - Mechanical 08/19/2011 $66.68
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 Notificatio Ccnt . 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 que ions to OUNC ca 503 32.1987 or 1.800.332.2344.
Issued By. t ' Permittee Signature: a vvi _ d, qul�L!` I.,(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.
Mechanical Permit Application w _r F:OR OFFICE USE ONLY
City of Ti and Received
it `1 g Date/By: A / '1 Permit I -#.93 /
N
13125 SW Hall Blvd., Tigard, OR 97223 Review
Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit:
T t G A R D Inspection Line: 503.639.4175 Date Ready/By: El See Page 2 for
Internet: www.tigard - or.gov 10 Notified/Method: Supplemental Information
It t't ,... In
TYPE O" ` OR � jC' N. COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
pp, f1,I Mechanical permit fees* are based on the value of the work
❑ New construction ❑ Addition /alteratioh/rep � performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: C, mechanical materials, equipment, labor, overhead, and profit.
Value: $
CATEGORY OF CONST :,�, ON RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 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: ASS 9 a sw EVVI p1 ke TEje, (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City /State /ZIP: -j-1 G4 le D t 0 f 9 Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: wA K E p 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:
,_- J DESCRIPTION OF WORK Water heater 23.32
((,� Gas fireplace 33.39
V eNT A T012. 12Q,A STE/2 Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32
Other: 23.32
Name: LAirn ELL WA K ED Environmental exhaust and ventilation:
Address: ` r n Range hood/other kitchen
� �' /� 1 a° I �� r� equipment 33.39
City /State /ZIP: L j ) wry � 7 0 R / 7 �Z4-- Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: (j "3) 72 ,2 £ 7ty Fax: ( ) toilet compartments, utility rooms) / 23.32 24 .3a.
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name: a (7 _ Other: 23.32
C 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
E -mail: Fireplace
Range
CONTRACTOR Barbecue
Business name: UAr Clothes dryer (gas)
Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) 10. (J
Plan review (25% of permit fee)
CCB lic.: State surcharge (12% of permit fee) )0_5-0
TOTAL PERMIT FEE lag,
This permit application expires if a permit is not obtained within I80
Authorized signature: a vv, d i /
�'1 days after it has been accepted as complete.
Print name: LA/44/4...L. L !n/ Ke- Date: —� / / * Fee methodology set by Tri- County Building Industry Service Board
17 �
I:\ Building \Permits\MEC- PermitApp.doc 09/09/10 440 -4617T (11 /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- PennitApp.doc 09/09/10 2 •
VQID
- ° Communi Develo ment <""
tY P
TIGARD Request for Permit Action _7S .c-t-&b ck//9///
cS
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: n Owner n Applicant n Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) / 4-
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (i):
CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available). ,P71._0 ( S ' CA S 47 6 i ,
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: H EC ( c)// - 00 S 6 S
Site Address or Parcel #: 15S 9 0 (.1D N/'/ i2 f._
Project Name: t-)Df} I t.b
Subdivision Name: Lot #:
EXPLANATION: P Q . / \ & Lb., rJ 6 o(Fi el ✓¢ L / 'TI:F t 5 ( S serTho6s
1-A of - 1 2 \ EAu Ati. P 1 iLti cr.
Signature: / t• Date: liq ' l 1
Print Name: -- D f E g - PC—D 6 -1
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date , ® l l Elora Rte to Bld. Admin: Date / /�Q' B O%-
Refund Processed: Date , A MPAN B itZil nvoice Processed: Date B
Permit Canceled: Date / AM B 1,(1 Parcel Tat Added: Date B
Receipt # f37/ Date . /9 // Me od C Amount $ 7,00 , ed
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGAR13
Receipt Number: 183713 - 08/19/2011 � AZ.6
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M EC2011 - 00365 $ 100.80
Total: $- 100.80
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 244067 DADAMSKI 08/19/2011 $- 100.80
Payor: Amell Waked
Total Payments: $ - 100.80
Balance Due: $100.80
Page 1 of 1
,! CITY OF TIGARD RECEIPT
• 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 183704 - 08/19/2011 0 2 l Gi i✓/4
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2011 -00365 Single Duct Exhaust (Bathrooms, Toilet, 230 - 0000 -43102 $0.00
Utility Rooms)
MEC2011 -00365 12% State Surcharge - Mechanical 100 - 0000 -24001 $0.00
MEC2011 -00365 Minimum Fee Adjustment - Mechanical 230 - 0000 -43102 $0.00
Total: $0.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT -
Credit Card 244067 DADAMSKI 08/19/2011 $100.80
Payor: Amell Waked
Total Payments: $100.80
Balance Due: $100.80
•
Page 1 of 1
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 701.325 (2))
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 a II subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
E I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
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 hom eowner statement is true and accurate.
v4'l'V��ZL- 1
Print Name of Permit Applicant
Signature of Permit Applicant Date
Permit #: M CC. AO — 00 3 o
Address: 5. 5 - ?0
02 -
Issued byk Ai Date: g //9// Fl
This Copy for Permit Offices