Permit CITY OF TIGARD MECHANICAL PERMIT
I
DEVELOPMENT SERVICES PERMIT #: MEC2004-00137
i 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 D ATE ISSUED: 3/23/04
PARCEL: 2S111 DB -12700
SITE ADDRESS: 09420 SW LAKE SIDE DR
SUBDIVISION: SUMMERFIELD NO.12 ZONING: R -
BLOCK: LOT: 678 JURISDICTION: TIG
CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS:
TYPE OF USE: SF UNIT HEATERS: VENT FANS:
OCCUPANCY GRP: VENTS W/O APPL: VENT SYSTEMS:
STORIES: BOILERS /COMPRESSORS HOODS:
FUEL TYPES 0 - 3 HP: DOMES. INCIN:
3 - 15 HP: COMML. INCIN:
MAX INPUT: BTU 15 - 30 HP:
FIRE DAMPERS ?: 30 - 50 HP: REPAIR UNITS:
GAS PRESSURE: 50 + HP: WOODSTOVES:
FURN < 100K BTU: AIR HANDLING UNITS CLO DRYERS:
FURN > =100K BTU: <= 10000 cfm: OTHER UNITS:
> 10000 cfm: GAS OUTLETS:
Remarks: Replace gas furnace
Owner: FEES
BURGESS, MARY B TRUSTEE Description Date Amount
9420 SW LAKESIDE DR
TIGARD, OR 97224 [MECH] Permit Fee 3/23/04 $72.50
[TAX] 8% State Surchaq 3/23/04 $5.80
Phone: 503- 639 -9629 Total $78.30
Contractor:
COLUMBIA HEATING + COOLING INC
P.O. BOX 230397
8900 SW BURNHAM #E1110 REQUIRED INSPECTIONS
TIGARD, OR 97223
Phone: 503 Gas Line Insp
Mechanical Insp
Reg #: LIC 76359
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore.
Specialty Codes and all other applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted in the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR
9.52101_010.0 You_ may_ obtain _copies_of irect questions to OUN_Cby
(503)246-6699.
Issued By: / Permittee Signature: ,,4)/2
Call (5 3) 639 -4175 by 7:00 P.M. for inspections needed the next business day
r
Mar 22 04 10:5,P. PAM DALBY 503- 598 -0270 p.2
A y f . ,
Mechanical Permit Application FOR OFFICE USE O L.Y
pp n Received as • Mechanical
RECEIVED ate/B : / Permit N./ - -
Cit of Tigaard ED Planning Approval Building
y b Date/By: Permit No.:
13125 SW Hall Blvd. Plan Review Other
Tigard, Oregon 97223 MAR z 2004 Date/By: Permit No.:
Phone: 503 -639 -4171 Fax: 503 -598 -1960 Post - Review Land Use
N7 } �� Date/By: Case No,:
Internet: www.ct.tigard.or . us CITY OF TI J. • Contact Juris.: lEl See Page 2 for
24 -hour Inspection Request: NALa'•k6 - Name/Method: Supplemental Information,
TYPE OF WORK .', COMMERCIAI IFEE *iSGHEDUL;E.= 'USE :CHECKLIST
❑ New construction 011111 Demolition Mechanical permit fees* are based on the total value of the work
ddition/alteration/replacement 101 Other: performed. Indicate the value (rounded to the nearest dollar) of all
CATEGORY OF CONSTRUCTION• :i', •
.. mechanical materials, equipment, labor, overhead and profit.
( 1 & 2- Family dwelling ❑ Commercial/Industrial Value: S See Page 2 for Fee Schedule
❑ Accessory Building ❑ Multi Family -. °RESIDlE1 I T: EQU. T1? MENNTIS'Y;STEMS.iFEE *::SOHEDULE •
❑ Master Builder ❑ Other: Description } try I Fee(ea.) Total
Heating/CootinP
JOB SITE INFORMATION and•LOCATION . - Furnace - add -on air conditioning ** / 14.00
Job site address: Gas heat pump 14.00
Suite #: Bldg. /Apt. #: Duct work 14.00
Project Name: Hydronic hot water system 14.0
Residential boiler
Cross street/Directions to job site: (for radiator or hydronic system) 14.00
•
Unit heaters (fuel, not electric)
(in wall, in -duct, suspended, etc.) 14.00
Flue /vent (for any of above) 1 0.00
Subdivision: i Lot , #: Repair units 12.15
Tax map/parcel r: Other Fuel Appliances
Water heater 10.00
DESCRIPTION OF WORK ' • Gas fireplace 10.00
1 / J 7e Azr i . �� , 7 4 � e7,/ Flue vent (water heater /gas Fireplace) 1 1 0.00
" 1 Log lighter (gas) 10.00
Wood/Pellet stove 10.00
Wood fireplace/insert 10.00
1 Chimney/liner /flue/vent 10.00
I PROPERTY.OWNER ' "1** D.:TENANT...•'r. . Other: 10.00
Name: . • ._ .Envlrohmental Exhaust & Ventilation
R a hood/other j
/1 T Qum Cr S Range hd/other kitchen equipment 10.00
Address: 92--e, , C(- ) (- I'' 4,44, ,(),
City, C lothes dryer exhaust 1 0.00
p 4( 97z z.' I
/ State /Zip: -7 Single duct exhaust
Phone: ,,7yi� / 9, , Fax: (bathrooms, toilet compartments, .
0 APPLICANT '❑:•CONTACT PERSON..' • utility rooms) 6.80
Name: Attic /crawl space fans 10.00 I
Address: - Other: ` 10.00
Fuel Piping
City/State/Zip; * *(55.40 for first 4, 51.00 each additional)
Phone: Fax: Furnace, etc. 1 **
Gas heat pump 1 **
E -mail: Wall/suspended/unit heater "" 1
CONTRACTOR . : • ' Water heater
Business Name: ( 1 4 -f- . COG /,A /6 Fireplace *"
Address: /0 D (3 e Range J.4, . � , 3 d -� q `> BBQ 1 .. 1
City /State /Zip: ---7-76. ,4 n 45 4) 97 3 *,
�7+ Clothes drye (,gas) I
Phone:S03 L 8 y ez'7,a/ I Fax: .5o3.SpP 0.7 7 Other: ••
CCB Lic. #: i Total: i
Authonzt d Mechanical Permit Fees*
Signature: C2l ,? _ Date: -Dal Subtotal: S
Minimum Permit Fee 572.50 S
PA , e fd A 'ci / by Plan Review Fee (25% of Permit Fee) S
(Please print - name/ State- Surcharge- (8- %- of- P- ersnit -Fee)- -5
TOTAL PERMIT FEE S
Notice: This permit application expires if a permit is not obtained within *Fee methodology set by Tri -County Building Industry Service Boa rd.
180 days after it has been accepted as complete. * *Site plan required for exterior A/C units.
i:Dsts`Permil Forms , ,Mcc PemlitApp.doc 01/03
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: (503) 639 -4171 MST
a , • BUP
Received ` X Date Re�estted — 7 /� y` AM BUP
Location e' Z-0 c:Z- l ?nom -L_ ' A -CJ Suite ( a -= ` �?
Contact Person o '�iYY� /� Ph ( ) (o Z < — Z7 J5Z PLM
Contractor Ph ( ) SWR
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Int Sheath/Shear
Framing - �.rl.� ✓�.cf./�C .r r���� /.C9C� G il ����°A--
Insulation /
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other:
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
Sanitary Sewer
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
Final
PASS PART FAIL
MECHANICAL`
Post: & Beam
Rough -In
Gas Line
S ke Dampers
F' aI
PART FAIL _
LECTRICAL -
Service
Rough -In
UG /Slab
•
Low Voltage
Fire Alarm
Final Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE Please call for reinspection RE: ❑ Unable to inspect - no access
- Fire Supply Line
ADA 1 j � O „
Approach/Sidewalk Date inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL