Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action VO I D r i c_, n I. r 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov . -3/i9/, 2-
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor '1`-' City Staff
(check one)
. REFUND OR Name: 1
INVOICE TO: (Business or Individual) i 1 / J-
Mailing Address: IIIVVV / 1 .
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: Hie Orot `a -oto 3540 •
Site Address or Parcel #: 1.0S42S atAD t)34 - Li..cf . s-r
Project Name: t'DfNLi.2 d 11) t• L£ .1.6.04
Subdivision Name: Lot #:
EXPLANATION: L o o Q ►�.7s... ►J f c k N'D 2 ee-oZ0 12 - Ob Ayl.
tAttit 140 litv KEtJ ou.-r - Cot,ot ell L. c. QTRAaTO2.
Signature: l ` Date: 7/i 9 / I a.
Print Name: ID A t € Q., Alpiii---111k. i
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
e) 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 2-4 weeks for processing refunds.
FOR. OFFICE USE ONLY
Rte to S s Admin: Date ' Rte to Bid: Admin: Date 7s'1® B t
Refund Processed: Date R By .t Invoice Processed: Date By
Permit Canceled: Date 0502_ By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPeimitAction.doc Rev 05/25/2012
Jul. 11. 2012 3:02PM V Ot P 7/9 q No. 8063 P. 1
Mechanical Permit ONLY
Applicatio F(.)R 01 01 LIME
City of Tigard �� /, I V �.. may. Permit Nog0e,, ��a._ 42 �
I
q 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 JUL 1 1 2012 nacre,. O1" "p °"y [Pao1..1-6009?
T l,; A I; r, Inspection Line: 503.639.4175 Date Ready/By: rune to See Page a for
Internet: Ntvwligardor.gov
CITY OFTIGARD NolifieNMelod: 1 /6 Supplemental !alarm Bon
ILD!NG DIVISION.. .
TYPE of wo COhflifERCIA1.'.FEE•,SCHEDULE - *A StRFCl3T-IV
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, ovcnc�� d profit.
Value• S ��
:00G 7l. Oil: COj 060.C71;1QNG::. 1lBSIDEM7ALEQ;JIP*NT, TEM$ 1►Elgb'*
❑ 1- and 2- family dwelling Commercial/industrial ❑ Accessory building For spedal h{Jbrmallo,i rue challis!.
❑ Multi family ❑ Master builder ❑ Other: Description I Qty. I Ea. 1 Total
Beating/cooling;
JOB SIZE INFORMATION AND LOt3ArIQI!�% '; Air conditioning
Job site address: 102 (S old p nv .�• . •. ) i-- (requires she plan showing placement) 46.75
City /StaICJZIP: ,rte furnace 100,000 BTU (ducts/vents) 46.75
( /' Furnace 100,000+ BTU (duclelveats) 54,91 ti
Suile/bldgJapt. no.: \ l J Project name:` . g Heat pump
r (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: I 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
LL �� Gas fireplace/insert 33.39
/
• •t n�0 {fit p 1 o , Flue vent for water heater or gas
NS Sc: , e 11L ' W M 1 1__ . 1JU� _ fireplace 23.32
11 S J `v' �r [ 7 Log lighter (gas) 23.32
SC;1- e,V , Cd7,S, Wood/pellet stove 33.39
Wood fireplace/insert 23.32
0 PROPERTY OWNER ❑ T`$N`AN'Y' :. ,. ..
Chimney/liner/flue/vent 23.32
Name: ' , l�I/7l 1 v .ICA'i IA (IC� ` Other. 23.32
r Ensironmenlal exhaust and ventilation:
Address: Range hood/other kitchen
equipment 33.39
City/State/ZIP: Clothes dryer exhaust 33.39
compartments.
Phone: ( ) Fax: ( ) tonal -duct exhaust (bathrooms. utility rooms ) 23.32
❑ APPLICANT , ❑ CONTACT PERSON Attic/crawlspacc fans 23.32
Business name: Other. 23.32
Fuel piping:
Contact name: 314.15 for first four; S4.03 for each a_ddltional_
Address: Furnace, etc.
Gas heat pump _
City/ State/ZIP:
.� Wall/suspended/unit heater
Phone: ( ) Fax; : ( ) Water heater
E -mail: Fireplace - -
Range
CONTRACTOR �+ Barbe
Business name: Ci`e, P�vC.►C Clothes d .er ( as)
�� C Other: 1 gas
Address: 20) qq-
f���
`� --�J� �� mniumcmpatals.,
City/State/ZIP: L— CA e... quo Subtotal
( Minimum permit fee ($90.00) 9 (117'- Phone: ( T3) �' D.. �Z I Fax: �e��;�, (0 - •551()
Plan review (25% of permit fee)
CCB lic.: r2-109, l t t . t \O State surcharge (12% of permit fee) 10
TOTAL PERMIT PEE 1 � j'�
Authorized signature: This pera It vocalist)
expir If a per mit is not obtain ,TOTAL
180 _
/ days offer It has been accepted as complete.
Print game: r-?--I'- xv. a+ �.-�p t - I Date: 1 -- 1 — i �, • Fee methodology set by Td- County Building Industry Service Doan!
I:nDohaiagt andint C-Pcrmin4,p.00e 03/07/i7 �^ �' a0a619T(tua17/co:wimp) C C 17 /A/ — o Gd c