Permit V CITY OF TIGARD MECHANICAL PERMIT
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II ° COMMU DEVELOPMENT Permit #: MEC2012 00531
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 10/16/2012
Parcel: 2S 111 AD04900
Jurisdiction: Tigard
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Site address: 8930 SW PINEBROOK ST
Project: Jacobs Subdivision: PINEBROOK TERRACE Lot: 72
Project Description: Installation of gas insert, gas line and venting.
;C Contractor: EVERGREEN GAS INC. Owner: JACOBS, R MARK & GLORIA E
`;: PO BOX 388 8930 SW PINEBROOK ST
,,, WEST LINN, OR 97068 TIGARD, OR 97224
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PHONE: 503 - 407 -9542 PHONE: 585 - 698 -5455
FAX: 503 -344 -6345
j.
FEES
Specifics: Description Date Amount
Gas Fireplace 10/16/2012 $33.39
Type of Use: SF Flue Vent for Water Heater or Gas 10/16/2012 $23.32
. Class of Work: ALT Type of Const: Fireplace
Occupancy Grp: Fuel Piping 10/16/2012 _ $14.15
12% State Surcharge - Mechanical 10/16/2012 $10.80
Stories:
• Minimum Fee Adjustment - Mechanical 10/16/2012 $19.14
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 estidons to OUl \by - ling 503.232.1987 or 1.800.332.2344.
Issued B _, O. ie. a 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.
Mechanical Permit A 1 Ili -' - F012 OFFICE USE ONLY
City of Tigard 1 EI'IIEIJ Date/By: lG Permit No.: Nee�p /�C� /
114 13125 SW Hall Blvd., Tigard,0' Received
Plan Review
Phone: 503.718.2439 Fax: 503.598.
0tur 1 6 20 12 Date/By: Other Permit:
T I G A R D Inspection Line: 503.639 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard - or.gov VA , OF T G D Notified/Method: Supplemental Information
% TYPE i DIVISION COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
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"
NI I - and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building For special information use checklist.
Multi - family 0 Master builder ❑Other: Description I Qty. I Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
Air conditioning
Job site address: 4 659 3 O "F., I : KI 5r- (requires site plan showing placement) 46.75
� /� Furnace 100,000 BTU (ducts/vents) 46.75
City /State /ZIP: / '
�. 4 t 7Z l Y Furnace 100,000+ BTU (ducts/vents) 54.91
Suite/bldg. /apt. no.: Project name: Heat pump
(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: 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/insert 1 33.39
2 ' i , i S 1 ( -4') 4 1 -r / .4 see- 'P t ve4- r ' '"�� Flue vent for water heater or gas
` S / 11.4- ( Log
fireplace 23.32
rf (9 L Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
PROPERTY OWNER ❑ TENANT Chimney /liner/ f_ 23.32
Other: 23.32
Name: `, ` 1 k_ "T a d 5 Environmental exhaust and ventilation:
Address: U) 3 �/ A c L k S i� Range hood/other kitchen
equipment 33.39
City/State/ZIP: -1 d-IL 9ZrV Clothes dryer exhaust 33.39
Phone: (5;95" , � . �7 / �5 Fax: ( ) Single -duct exhaust (bathrooms,
� J toilet compartments, utility rooms) 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic /crawlspace fans 23.32
Business name:
Other: 23.32
Fuel piping:
Contact name: $14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City/State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater tt
E -mail: Fireplace
Range
CONTRACTOR Barbecue
Business name: -7, �l/C- ✓ ^pro,.` S z '/�. L Clot es dryer (gas)
Address: ``..., 3 , Q MECHANICAL PERMIT FEES*
City/State /ZIP: (JSyL e ,, �7L '7/)6 e Subtotal
Phone: L
.j)) 07 _ oy Fax: c/ ) 3 /57 (O/ J ? 7 / Minimum permit fee ($90.00) 1 94. 0 "
/ Plan review (25% of permit fee) �—
CCB Iic.: /.....5-3 0 3 , lAtigil � State surcharge (12 %ofpermit fee) /0. sz
� 1 /// TOTAL PERMIT FEE /00. f
This permit application expires if a permit is not obtained within 180
Authorized signature: days after it has been accepted as complete.
Print name: (n) i f ik r tic bet e-c-L_ Date: /0/4/2__ • Fee methodology set by Tri -County Building Industry Service Board
I:\ Building \PermitsUMEC- PermitApp.dac 03/07/12 440-4617T (I 1/02/COM/WEB)
Mechanical Permit Application City of Tigard .s f
Page 2 - Supplemental Information !" s
Commercial & Multi - Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to $500.00 Minimum fee $69.06
$500.01 to $5,000.00 $69.06 for the first $500.00 and -
$3.07 for each additional.$100.00 or
fraction thereof, to and including
• $5,00000.
$5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and
''$2.81 for each additional $100.00 or
fraction thereof, to and including .
$10,000.00:
$10,000.01 to $50,000 .00 $347.71 for the first $10;000.00 and
$2.54 for each additional $100.00 or
fraction thereof, to and including
$50,000.00.
$50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and
$2.49 for each additional $100.00 or
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first $100,000.00 and
$2.92 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
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