Permit ,, CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: MEC2012 -00012
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/13/2012
Parcel: 2S104AD02300
Jurisdiction: Tigard
Site address: 12535 SW 128TH AVE
Project: FOERSTER Subdivision: BELLWOOD Lot: 50
Project Description: Gas fireplace insert replacement.
Contractor: NW GAS LINES Owner: FOERSTER, JAMES W AND
16731 NE WASCO ST JO NELLE
PORTLAND, OR 97230 12535 SW 128TH
TIGARD, OR 97223
PHONE: 503 - 256 -2436 PHONE:
FAX: 503 - 256 -2245
FEES
Specifics: Description Date Amount
Gas Fireplace 01/13/2012 $33.39
Type of Use: SF 12% State Surcharge - Mechanical 01/13/2012 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 01/13/2012 $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 questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee 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.
Jan 12 12 01:12p Tony Young 503- 256 -2245 p.1
Mechanical Permit Application a,, l,� ' "' FOR OFFICE USE ONLY
a }
City � of Tigard a ;:m Received
Date/By: �� >> Permit No.: r � '
r
13125 SW Halt Blvd., Tigard, OR 97223 AO'a _ °W
v
IN
Phone: 503.718.2439 Fax: 503.598.1960 JAN 1 2 2012 ew
Date/By: Plan Revi Other Permit:
TIGARD Inspection Line: 503.639.4175
Internet: www.tigard- or.gov � _ Date Ready /By: hris: ® See Pnge 2 for
CITY Tl VF TIGARD Noti fied /Method: Supplemental Information
Pi ill 1)1Ar Ill \tiSii ?��i
TYPE OF WORK __ COMMERCIAL FEE" SCHEDULE - USE CHECKLIST
/ Mechanical permit fees* are based on the value of the work
New construction
❑ ddition/alteration. replacement . performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition Other: mechanical materials, equipment, labor, overhead, and profit.
CATEGORY OF CONSTRUCTION Value: $
RESIDENTIAL EQUIPMENT /SYSTEMS FEES"
1 -and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building Forspecio tinfwnsalionusecheckiisa
Multi - family ❑ Master builder
❑ Other: Description I Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Hcating/ctloling:
/� t53 / ? Air conditioning
Job site address: �� � j�j�fo (requires site plan showing, placement) 46.75
City/State. /ZIP •�;`"a,�Q 6Y 9' 7 -v ^ !,�' Furnace 100.000 BTU (ducts/vents) 46.75
� �.j r/d /O`P Furnace 100.000+ BTU (ducts /vents) 54.91
Suite/bldg.:apt. no.: L/ 1 Project name: Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 2332
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
,.y //� 3.32 ]
�kG "�4 r ✓/ se� f- Gas fireplace eplace / 33.39 1
Flue vent for water heater or as
fireplace 23.32
Log lighter (gas) 23.32
Wood /pellet stove 33.39
Wood fireplace /insert 2332
PROPERTY OWNER ❑ TENANT 23.32
/// ��— j � Othen 23.32
Name: .� C I Q l
�r'� e Environmental exhaust and ventilation:
Address: Range hood /other kitchen
/ equipment 33.39
City /State/ZEP: l i/LC,6 -• Clothes dryer exhaust 33.39
Phone: Single -duct exhaust (bathrooms,
( ) Fax: ( ) toilet compartments, utility rooms) 23.32
Vf APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name: n � I /f ,-� l / f /� �f/j/JJ / G _ � 4 / /) , 1 Other: 23.32
'L Fuel piping:
Contact name: r
y (,.rid j .) R. U/� shes $14.15 for first four; $4.03 for each additional
Address: / /_ /
/ ,{ / �� ii s he h p
V - G aas at pump
City /State/21P:
LC I /' 77 i b Wail/suspended/unit heater
Phone: (`53 ,_2,5-6,—,(2k,3 6 Fax: : ( ) S6, _c,2ay.S Water heater
E -mail: I: a Al � I4 Rang
� _ � e Range e
CONTRACTOR ' Barbecue
Business name: / L & � Clothes dryer (gas)
/ � l Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: c` T Subtotal
Phone: ( ) Fax: ( } Minimum permit fee ($90.00) C 10.01.)
/57.-/ r , Plan review (25% of permit fee)
CCB lie.: t7 C')!( State surcharge (12% of permit fee)
TOTAL PERMIT FEE / atu
Authorized signature: This permit application eapires if a permit is not obtained within HID
days after it has been accepted as complete.
Print name: L ye7 ,� � G) Date: / / p / • Fee methodology set by Tn- County Building Industry Service Board
I:' Building 'Permit,MEC- PermitApp.dce 09/09/10 ''v J 440-4617T (1 N7oCOs5M'EB)