Permit 131 \I Z-7 cHwy
E IRE • r ! r'",,
Mechanical Permit Application ,,. FOR OFFICE USE ONLY
i Received i A Pemut No. �.2Q a 8 7w3
13125 SW Hall Tigard Blvd.,Tigard,OR 97223 Y� PlaDate/By:eview y�,f Other Permit: i
Phone: 503.139.4171 Fax: 503.598.196 is;.,,,,.,,; "A Date/BY: Viir11101l9tt�i.`-:' g ��i-�.2y
Inspection Line: 503.639.4175 ,�1 e`1 i1 Date Rea, 1v 'um' 65 See Page 2 for
Internet: www.ci.ti ard.or.us "'O Supplemental Information
8 Notified/Method:
, 110,01r. CO. 4.= ';
1 Yt : i 1� 1' r ,y+„ ,d'* '!1 9 b^ S iii'F x �iM t' ,4 `� - { f KI:JIST
,a' ,, .( 1 N:r nrt rr! t. j,.4 "'m` oZ" ti „•it,,.,. <.4 < s ' CO. ”, 'AL FEE SCH pLILI; USECAEO• Mechanical permit fees'are based
❑New construction ,Addition/alteration/replacement the value a work
performed.Indicate the value(rounded d to the l ue nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,end profit.
# d. e u • `,. . MI , i , i? c;<F w ,c'. Value:S
.'9'��l, ! `o g'rJ , } a' ,,Y }�'�i t 1 1 ,a t" c7 i.... k,t,.-. . 'i.,:+,. I.,'..'v6 �Q
'-' RUr SIbE7�T AZ.,?E0011'10NT/SfSTEMS FEES*
❑ 1-and 2-family dwelling commercial/industrial ❑Accessory building
For special information use checklist
❑Multi-family 0 Master builder ❑Other: Description Qty. Ea J Total
t. ;:t. f Vet". .i'!rt,riLi:-
M�.it'''tti t a C t t Q re r Usg , t -.3 ,k,.�.Lt s ,,. . Heating/cooling
Air conditioning or heat pump
Job site address: • I 11
i� !(,� � (requires site plan showinp,Jilacement)
14.00
City/State/ZIP: 1 1 ax6 0 1 100,000 s
l Furnace 100,000+BTU(ducts/vents) 17SO
Suite/bldg./apt.no.: I Project name: lQy VI t w #S Gas heat pump 14.00
Cross street/directions to job site: Duct work 14,00
Hydronic hot water system 14.00
Residential boiler(radiator or
hydronic) 14.00
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 10.00
Subdivision: ! Lot no.: Flue/vent for any of above 10.00
Other: 10.00
Tax map/parcel no.: Other fuel appliances _
t!,i'"(1,.,4',1•-qt,'i ^i'4F 7 �'Iti ' ,tr ?i ,ii*: 774-1"1,tih`'''�,JP.,?St(6 U' i '.',4 r� r 1;r;r 1 s.ii1lti i Water.heater 10.00
¢alts,:. v :,,- ',Aiit1:'S).1 .i.,u.,:.,,, -, r ._ ._1_.,,..._ „e::.'..L.st s7,.r.$..cit-,3.u. i'r,thtui.
Gas fireplace 10.00
�^A - . (a) O'er r p 4 `-3 (./LA3 Flue vent for water heater or gas
EX,{' aj(91- 4- ,,Q d /1 C n ' Q n, 1_ f,,�� •l fireplace 10.00
L�Jf-!C tea lwlk9 (�l�lam+ Log lighter(gas) ,
W UY 'v . Wood/pellet stove 10.00
Wood fireplace/insert 10.00
." .. . 10.00
r _ � >t'l ori v �L �y` , � i , w1 F� Chimney/iner/flue/vent
.,� �s:1El .P.L ... atil,,,,da�..e �9� .,,:ti " 1 4 . : Other:
10.00
N'„e: Environmental exhaust and ventilation
...- ' Range hood/other kitchen
Address: equipment 10.00
City/State/ZIP: Clothes dryer exhaust 10.00
Single-duct exhaust(bathrooms,
Phone:( . ) 14 jai Fax:( ) ` . toilet compartments,ompartments,utility rooms) 6.80
'1,.., t{iil,1,1U1I� „; ' 11 (II it i t i(f 'e ;1l;1t( (i�ffr h 4!",„ ps,II�1< I�lAttie/Crawl ace fans 10.00
,: .ti.,a,.,� .4,nut1 t.,t4ii:V.n,-.1 .41nli,i,.1•I,t',I F.,. c,kiY-isa .�,1...�:o,■• a .xn< n,, Other: 10.00
Business name: II"Ma(t 11 *a.1-7 nv 1 ` A'1r, Fuel piping
Contact name: U Ct $5.40 for first four;$1.00 for each additional
Address: rnCl SL .i( Qan 9 , ,Furnace,etc.
Gas heat pump
City/State/ZIP: `�%V .((ma ( cQ qi?-(' Wall/suspended/unit heater
Phone:69)) a' _4 Goo Fax: :( (R) 21_703(8'
ld l 7 OE(8' Water heater
�� Fireplace
E-mail: Range•N , i 1 rIruy III. [Q0) 4i tr !1 ,� �'. Barbecue
�,...L. 1... l�..U�
Business name: \' r\(mil •(�``-l`c)q (Sir'�t[ f Otheres dryer(gas)
Address: l 1 Se 6 l�z J a. r . po . ` ,rdn
City/State/ZIP: 1-11-.04-{,Col a � -)0 a Subtotal ` '0 ,',
eb b U ( Q ) a-J� �03� Minimum iew(2 % fee permit f.0
Phone:t ()� � I Fax:(� `�
� Plan review(25%of permit f•� aa ,'4.3
CCB lic.: .3 \- _s--- I State surcharge(8%of permit fee)
� ,re l." ' "-` , ��`+� 1 TOTAL PERMIT FEE /X41.n I
Authorized signature: I II This permit application expires If a permit is not obtained within 180
tn., days after It t ar been accepted as complete.
ti
Print name: t T t M_/a r 0 V 7 �� Date: /� u "G a • Fee methodology set by Tri•County Building Industry Service Board