Permit . CITY OF TIGARD MECHANICAL PERMIT
` 2 COMMUNITY DEVELOPMENT Permit #: MEC2011 -00580
Date Issued: 12/15/2011
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439
Parcel: 2S110DD04500
Jurisdiction: Tigard
Site address: 15645 SW OLD ORCHARD PL
Project: CLARK Subdivision: SUMMERFIELD NO.3 Lot: 147
Project Description: Gas fireplace insert.
Contractor: RICK STICKA LLC Owner: CLARK, DALLAS EDWIN LIVING TRUST
686 S 25TH CT 15645 SW OLD ORCHARD PL
CORNELIUS, OR 97113 TIGARD, OR 97224
PHONE: 503 - 680 -1046 PHONE:
FAX:
FEES
Specifics: Description Date Amount
Gas Fireplace 12/15/2011 $33.39
Type of Use: SF 12% State Surcharge - Mechanical 12/15/2011 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 12/15/2011 $56.61
Occupancy Grp:
Stories:
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 • stain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. /
Issued By: 0 11111111.11. _ Perm!'ee Signature: -�
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 051) F:Oi o.FFICE USE ONLY
City of Tigard �� R eceived
Date /By: 15 j AO Permit No.: C i [ -
n 13125 SW Hall Blvd., Tigard, OR 9 ' �
Phone: 503.718.2439 Fax: 503.59 ` 1,0� Plan Review
Date/By' Other Permit
T IG A R D Inspection Line: 503.639.4175 �¢� ,„s Date Ready /By: lur s: See Page 2 for
Internet: www.tigard or.gov �� O �Q� lS t�O , ` Notified/Method: �y> Supplemental Information
TYPE OF WOR �1`. COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
�v Mechanical permit fees* are based on the value of the work
El 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: $
CATEGORY OF CONSTRUCTION RESIDENTIAL. EQUIPMENT / SYSTEMS FEES
I - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist.
Multi - family 0 Master builder 0 Other: Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: `3 115 S • dLA 0 r .(> C (requires site plan showing placement) 46.75
City /State /Z1P: �" Furnace 100,000 BTU (ducts /vents) 46.75
CJ �Z Q Furnace 100,000+ BTU (ducts /vents) 54.91
Suite/bldg. /apt. no.: Project name: 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
_ Gas fireplace j 33.39 , 3
6 i /1 ,y12g>:�/`'T�i -3 ‘7 1/ L7? / Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
91 y n ∎t -e��y Cam 3 t. Wood/pellet stove 33.39
/ Wood fireplace /insert 23.32
1' PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32
/ Other: 23.32
Name: Da ( I A_ S L,zx Environmental exhaust and ventilation:
Address: .{ cl it/ QL6 O� c L Range hood /other kitchen
l S 7jt equipment 33.39
City /State /ZIP: � 6 a�. O/2--- Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone: ( ) Fax: ( ) toilet compartments, utility rooms) 23.32
'APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name: r r Other: 23.32
/7 ST , /t L L C- Fuel piping:
Contact name: / / C - �/ .7 / '-K. & $14.15 for first four; $4.03 for each additional
Address: / e C 2 L7-s. Furnace, etc.
Cit /State /Z1P: t a
Gas heat pump
y ��i�L Zlj C/ Wall/suspended/unit heater
Phone: ( ) /'666 __AO y Fax: : ( ) Water heater
E -mail: Fireplace
Range
CONTRACTOR Barbecue
r Clothes dryer (gas)
Other:
Business name / � '-� l � A L r
4 r
Address: 4 g--6 S ��L% MECHANICAL PERMIT FEES*
City /State /ZIP: ( a e. L' m �2 4 13 Subtotal 33 ;1
, t
u�� pa ( ) Minimum permit fee ($90.00) 7V-
Phone: ( )
3 C�g0 Plan review (25% of permit fee)
CCB lic.: / 9 D G� /i( State surcharge (12% of permit fee) iO s_ / TOTAL PERMIT FEE t) , RO
Authorized signature: This permit application expires if a permit is not obta ed within 180
g - days after it has been accepted as complete.
Print name: / ?ir-C c � C,' A. Date: * Fee methodology set by Tri- County Building Industry Service Board
P\ Building \Permits\MEC- PermitApp.doc 09/09/10 440 -46I7T (I I /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.
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