Permit j,/o /A -Nb 26 -�
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Request for Permit Action u E �. s 'p m
TIGARD AUG
C1 11
TO: CITY OF TIGARD 8(I/C Af T 0
Building Division Services Coordinator u /Vin �N
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner n Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name: 471. INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
ET CANCEL PERMIT APPLICATION. P tb
❑ REFUND PERMIT FEES (attach receipt, if available). ‘,/-
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: MEd, oqo e t- od 371
Site Address or Parcel #: I ( 2$ 0 e at.° LAPP £2 Pacrwas re24
Project Name: a-( & 6 .P g c
Subdivision Name: Lot #:
EXPLANATION: \p Pe&H ,r Az coaTRRc%02.
btut -t IJtitJ PC.+4a5 fog k & -- rinJx1 - 1 , 1 •
Signature: • ! Date: ( ///
Print Name: 1 t /aj6/
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) 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 aggillilat Rte to Bld: Admin: Date / 47 B ;ger
Refund Processed: Date A/.9- By , :t. , Invoice Processed: Date By
Permit Canceled: Date I / /!/ //f By . ■7 Parcel Tag Added: Date By
Receipt # Date / Method Amount $
I:\ Building \Forms \RegPemutAction.doc Rev 07/26/07
Mechanical Permit Applicatl'j 7 -- - - -, FOR OFFICE USE -ONLY .. .. .
City of Tigard 20 \� b
Received
,,``G Dat /By: D /d / - i Permit f��/fl")
7 3
lig 13125 SW Hall Blvd., Tigard, OR 97223 ph � ' vv
p j Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 r J r1.A Other Permit:
1 1 Date /By.
Inspection Line: 503.639.4175 �.�j Q �'� � �a \' orris
T I GARD CAA b � 14� - Date Ready/By: 0 See Page 2 for
Internet: www.tigard or.gov
15‘11‘331� Notified /Method: Supplemental Information
'fi Z: ` ` .,.r, ` / T YPE Of415R 5 .: 1V - s „ i C OM iiitif IAL FEE* `'SCIIE:DULE USE CHECKLIST "
.7 ". i.t :, , :,,A :,, r.. x _,a._, . .. — _ , ....
Mechanical pennit 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.
Value: $ $4,000.00
«.
C, A�,,.GOY OF \ C .. _ONSTRUCTION S ' x ` 'RE L EQ i S ,
y . , - ,. TER
< ., ti. .- , _ _�. _ _ , '_ "° i{ SIDENTIA �" UIPMENT ASYSTFMSFEF
❑ I - and 2- family dwelling ® Commercial /industrial ❑ Accessory building For special information use checklist.
❑ Multi- family ❑ Master builder ❑ Other: Description Qty. I Ea. I Total
POriV t 11, JOB IT
SE ; INFORMA T ION N
AD LOCeATION O ; r„ Heating/cooling:
Air conditioning
Job site address: 16280 sw bonnes ferry rd (requires site plan showing placement) 46.75
City/State/ZIP: Portland Or Furnace 100,000 BTU (ducts /vents) 46.75
Furnace 100,000+ BTU (ducts /vents) 54.91
Suite /bldg. /apt. no.: Project name: PCB 16280 p i e e 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:
y A ` "" DESCRIPTION OF a 4 : ia` a Water heater 23.32
Gas fireplace 33.39
modify ductwork, add new t -bar grills and insulate spiral duct as needed Flue vent for water heater or gas
install (1) unit heater, relocate (1) - 2 ton rooftop unit fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
' ` PROPERTY OWIVERz n �-J ° v ' ' ' `x ^ ®t T ENANT Chimney /liner /flue /vent 23.32
t . ,u . 0,,.a. ,- 1,. „max u .uaq 4I ,.,.... , ., cs _ .� , ..gym <, ,.> ..
Other: 23.32
Name: pac trust Environmental exhaust and ventilation:
Address: Range hood/other kitchen
equipment 33.39
City /State /ZIP: Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: ( ) Fax: ( ) toilet compartments, utility rooms) 23.32
`� 0 �� . ® AP ' ,
NT, „ S ,
r_ P t an ' as. -GONTA Attic /crawlspace fans 23.32
Business name: Arjae Sheet metal Other: 23.32
Fuel piping:
Contact name: Heath Burmeister $14.15 for first four; $4.03 for each additional
Address: 8545 Se mcloughlin blvd. Furnace, etc. -
Gas heat pump
City /State /ZIP: milwaukie or 97222
Wall/suspended/unit heater _
Phone: (503) 231 - 7717 Fax: : (503 - 230 - 4888 Water heater
Fireplace
E - mail: heatth @arjae.com '0 -- .e2 ' — O iCi l 2 L. Range
f .,; al a CONTRACTOR; , i,,.t��.::,, Barbecue
dryer ryer (gas)
Business name: Arjae Sheet Metal Clothes -
Other:
Address: 8545 SE McLoughlin !. ” `, ECIIANIGALiPERMIT EEES� ; i
City /State /ZIP: Milwaukie OR 97222 Subtotal
Phone: ( ) 231 - 7717 x: ( ) 2304 Minimum pennit fee ($90.00)
/ Plan review (25% of permit fee)
CCB lie.: 60835 State surcharge (12% of permit fee)
TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within ISO
Authorized signature:
/ days after it has been accepted as complete.
Print name: , ' / g• ( y '1/L. — Date: .6 to (( * Fee methodology set by Tri- County Building Industry Service Board
I. \Building \Permits \ MEC- PermitApp.doc 09/09/10 440 -46I7T (11 /02 /COM /WEB)