Permit CITY OF TIGARD MECHANICAL PERMIT
••• - COMMUNITY DEVELOPMENT Permit #: MEC2011 -00593
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 12/21/2011
• . Parcel: 2S103BB01400
Jurisdiction: Tigard
Site address: 12476 SW BROOK CT
Project: Zagorodney Subdivision: BROOKWAY Lot: 14
Project Description: Install gas insert
Contractor: NW GAS LINES Owner: ZAGORODNEY, WENDY M & DAVID L
16731 NE WASCO ST 12476 BROOK CT
PORTLAND, OR 97230 TIGARD, OR 97223
PHONE: 503 - 256 -2436 PHONE: 503 - 319 - 0805
FAX: 503 - 256 -2245
FEES
Specifics: Description Date Amount
Gas Fireplace 12/21/2011 $33.39
Type of Use: SF 12% State Surcharge - Mechanical 12/21/2011 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 12/21/2011 $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 obtain a copy of the rules
or direct .. - 'c s to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: / Permittee Sign• ff 4 ,`
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.
Dec 20 11 08:50a Tony Young 503- 256 -2245 p.1
Mechanical Permit Application, FOR OFFICE USE ONLY
City of Tigard Deceived
Dater 62 /l / Permit No.:
13125 SW Hall Blvd., Tigard, 0 23 v_ � ..� � �
') Q1 \ Plan Review
Phone: 503.718.2439 Fax: 503.598.196 q Q l- Date/By: Other Permit:
T] GA Ti Inspection Line: 503.639.4175 Ca f � 0 Date Ready/By: tarts: 0 See Page 2 for
Internet: www.tigard- or.gov � OG rckG t � C � 0 0 Notified/Ivied Supplemental Information
TYPE O` J COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
5 z . Mechanical permit 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: $
CATEGORY OF CONSTRUCTION
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 Heatiagicaoling:
f� Air conditioning
/
Job site address: ' 77, "`TT' \ G (� e,-,&41,e G (requires site plan showing placement) 46.75
City/State/ZIP: �/ I C� ASS Furnace 100,000 BTU (ducts/vents) 46.75
y /State/Z1P: - / � , k f- VY J 7r. : � t . — 3 Furnace 100,0004- BTU (ducts/vents) 54.91
Suite /bldg.iapt. no.: Project name: Heat pump
(requires site plan showing placement) 61.06
Cross streetidirections to job site: Duct work 23.32 ,,
Hydronic hot water system 23.32
Residential boiler (radiator or
bydronic) , 23.32
Unit healers (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 . 33.39
/s.//j/ Flue vent for water heater or gas
fireplace 23.32 Log lighter (gas) 23.32
Woodlpellet stove 33.39
�[ Wood fireplace/insert 23.32
�J PROPERTY OWNER ❑ TENANT Chimneyfliner /flueh'ent 23.32
/ Other: 23.32
Name: , el 67 Environmental exhaust and ventilation:
Address: Range hood /other kitchen
it-L equipment 33.39
City /State/ZIP: Clothes dryer exhaust 33.39
• / '�
Single -duct exhaust (bathrooms,
Phone:
( ) t. / Jrl) g Z) Fax: ( ) toilet compartments, utility rooms) 23.32
APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
J Other: 23.32
Business name: b My' fj� J _�, J Iii Vifi 6,4,2,- Fuel r rn
CJ/ �1OJ�°'� 6�7� !Y3 P�P g�
Contact name: y / I j r e-r4" ` /,r � J 514.15 for first four; 54.03 for each additional
Address: l /�{L� / � 1 � Furnace, etc.
��� /Y� Gas heat pump
City /State /ZIP: (/ 120 tI y Wall /suspended /unit heater
(523) a y� y 36,..„ 5Z3 /__. �. Water heater
Phone: Fax: : (` JG J) (f/
,C Fireplace
E-mail: f t�i�rPs / �� (S L r) l } (1 St' )1(-/ Range
CONTRACTOR Barbecue
Business name: /� 1 (/ {/, �, eS Clothes dryer gas)
G r J Other:
Address: MECHANICAL PERMIT FEES*
a
City /State /ZI Subtotal
Phone: ( ) Fax: ( ) 2 5 Cf[ -'- 2 / 5 Minimum permit fee permit fee)
Plan review (25% of permit fee)
CCH tic.: /91 (I State surcharge (12% of permit fee) / TOTAL PERMIT FEE O ge _
477/64'6.
;' 7/64'6. . This permit application expires if a permit is not obtained within 180
Authorized sign / / azure: '/ ) days after it has been accepted as complete.
Print name: / /d i g y Date: /de7v f� ' Fee methodology set by Td -County Budding Industry Service Board
1113uilG ng lPermitsVMEECC-- t PermitApp.doe /10 440-461,T( I t,02/COM/WER)