Permit • City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V ®1 0
III
11 0111
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319/1 Request Permit Action
2_
r r ( ; A 1. r_) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
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 cirContractor ❑ City Staff •
(check one)
REFUND OR Name:
i‘
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.: .
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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 #: l Se. AO 19.--00 9 )7 3
Site Address or Parcel #: f /A 30 ) 4-DOa- V2 # 5
Project Name: 0pk6--i Tj £ ec j os
Subdivision Name: 1Jl 7- Lot #: /OM
-
EXPLANATION: eVfile.,.74.-- 64- /t / /e,
Signature: U Date: 7
Print Name: J Ok„ 1/' ,Beo/
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) 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 - weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ?jEnni. B. " Rte to Bld • Admin: Date ��® :fir
Refund Processed: Date A/ i - By Invoice Processed: Date 9 /9 /z By / .
Permit Canceled: Date AV/ Z By - Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPemutAction.doc Rev 05/25/2012
Mechanical Permit Applica 'o FOR OH I( is 1 S1. (>Ni.l
City of Tigard 1
1 Received 7 /17 4,. Remit No : MECaO /a - �O ?
II , 13125 SW Hall Blvd., Tigard, OR Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 g� A`! , , l Permit
Inspection Line: 503.639.4175 Ms: El See Page 2 for
Internet www.tigard-or.gov 7 /r
�r.gov / � JUL 17 2012 No / e Supplemental Information
TYPE of woRI� OF man
�` " PM' * SCHEDULE r USFC 1'
N ew construction . 'cal permit ices* are based on the value of the work
❑ erAddition/alterati DIVISION performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit
Value: $ /431iS
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/ SYSTEMS FEES'
❑ 1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory build For special orlon radon we checklisL
0Multi- family ❑ Master builder ❑ Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Beating/cooling:
r� Air conditioning
Job site address: �12 ?� �Cw z2eafdw / /' UH/ j43 (requires site plan showing placement) , 46.75
Furnace 100,000 BTU )
City /StaterLIP: T (O 9222Y Furnace 100,000+ BTU (ducts/vents) ) 54.91
Suite/bldg./apt no.: 0 I Project name: Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
� / gym Hydronic hot water system 23.32
AT P �
j /1 / SU in in or 1 Residential boiler (radiator or
/YIe�D w /7rPOk 1)/i h dronic 23.32
( 6s5) e- 7 !
Unit heaters (fuel-type,
ct sus pe dad electric), 75
Subdivision: l Lot no.: Flue/vent for any of above 23.32
in -wall, irh•duct 46.7
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
Gas fireplace/inset 33.39
Flue vent for water heater or gas
Aiiu'nd . ilf& ., —lD Air, Pelf 1 Duple k lighter (stag) 23.32
Wood/pellet stove 33.39
Wood fireplacelmsert 23.32
❑ PROPERTY OWNER I ❑ TENANT Chentey/liner /flue/vent 23.32
Odd 23.32
Name: SU/1 efer∎Wi l sx e L � , Environmental exhaust and ventilation:
Address: ///75 S/,✓ ineodow llro0k Pr/ v a otter kitchen 3339
City/State/71P: 7 ,-,,,a . /9re . 9722y Clothes dryer exhaust 33.39
V9‘5" Single-duct exhaust (bathrooms,
Phone: (S03) 6 !//- /i9/ Fax: (503 68*'- Y99 toilet compartments, utility rooms) 23.32
APPLICANT ❑ CONTACT PERSON Attidcrawlspace fans 23.32
Other 23.32
Business name: .7 8 �� r& /.;e L 0 Fuel tbpimt:
Contact name: J R - $14.15 for first tour, $4.03 for each additional
Address: A S _ NG r f 0 Furnace. etc.
DP: Gas heat pump
City/State/
�1/ , Ore 9 71/3 Wawsuspended/tmit heater
Phone: (503) )60 7035 I Fax:: (5'03 ) . 2 9q- y'o23 Water heater
place
E -mail: 7" gaols 6,..ci e ins . eafryi Range
CONTRACTOR _ Barbecue
Business mine: Clothes dryer (gas)
���1 AS AA. PC ���I /(tDA/ Other. .
Address:
MECHANICAL PERbnT FEES`
City/State/ZIP: Subtotal
MinimumFennit fee ($90.00)
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB lie.: /99 g 2 Q State surcharge (12% of permit fee)
Q TOTAL PERMIT FEE
Authorized signature: 8,0___ Thi permit application expires if • permit n not obtained within 180
days after it has been accepted as complete.
� /
Print name: Ty y / Date: 7 - - Z • Fa methodology set by Tri- County Building Industry Service Board
1:\Buildinthrmin C- tApp.doc 03/07/12 440-4617T (I L02/COM/WF8)