Permit Support Document (101) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMLI
Request for Permit SEP 1 2016
q e nut Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ` L TVA i L)
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TO: CITY OF TIGARD V I
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Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 9//x/1'
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 0 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) N//41—
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
►j! CANCEL/ 'OID PERMIT APPLICATION.
• r 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#: H1;Cc-0 t (D-- OO5-1L
Site Address or Parcel#: r a§e.v P -Q t F, c I4w> 710
Project Name: �j j L�-�t �� Cy(2-05
Subdivision Name:
t (� Lot#:
EXPLANATION: iSLo D t S 4X/5-r►►J , P€Q.Mt i PiP P L1 eh-T-1 o (5H-ow.b
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Signature: Date: 9/�/‘
Print Name: Dt ,4 /4-1D4.444/.
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date 9 G � ./ Route to Records: Date 9 f / , By - 1
Refund Processed: Date A/,4 By Invoice Processed: Date By
Permit Canceled: Date Mt,//f., By P '' •arcelTa• Added: Date By
I:\Building\Forms\RegPermitAction_0{)231 doc
Mechanical Permit Applicatiti I .. FOR OFFICE F SF Oy1.1
III q City of Tigard �`'eceived �I
: (� ' —y 6ai. Permit NoE tJ` � t%�
• 13125 SW Hall Blvd.,Tigazd,OR 97223 g / fi z Plan Revtew! z /• i%�- 6
Phone: 503.718.2439 Fax: 503.598.1960' 'a g Date/By: Other Permits u�0�/6 ,_/�7n�3(�
T I G A R D Inspection Line: 503.639.4175 Date Read B Juris: +'' LWL/ t7
Internet: www.tigard-or.gov n{ t Ready/By: See Page Supplemental2 for
,19 i 2 Z.II l0 Notified/Method: Information
.. _..�..,��/�.,ate > ;;
€ri-o 6 Mechanical permit fees*are based on the value of the work
®New construction 0 Addition/alteratloil/replacement performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit.
.' Vall6ue $$3,800 00
„ ' 3r, r ,ski/:' ,moi/c ...
❑ 1-and 2-family dwelling ®Commercial/industrial 0 Accessorybuilding
For special information use checklist.
❑Multi-family 0 Master builder
0 Other: Description Qty Ea. Total
1441 M i # * r #: a t # # Heating/cooling:
Air conditioning 46.75
Job site address:13815 SW Pacific Hwy Furnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP:Tigard OR 97223 Furnace 100,000+BTU(ducts/vents) 54.91
Suite/bldg./apt.no.: Project name:UL300 FS Heat pump 61.06
// ! 1 21/ &— Duct work 23.32
Cross street/directions to job site:SW Mcdonald Street and Pacific HWY 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
Flue/vent for any of above 23.32
Subdivision: I Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 23.32
cr. ' ,, z #1„ #t # 1# �` r. Gas fireplace/insert,,..� .�,,, ,,.. , .,, . ,� P 33.39
Flue vent for water heater or gas
Installation of the UL300 wet chemical fire suppression system to protect a type fireplace 23.32
1 exhaust hoods. Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
23.32
� ' . % '' '/ .. Environmental exhaust and ventilation:
Name:Mike Range hood/other kitchen
Address:13815 SW Pacific HWY equipment r 33.39
Clothes dryer exhaust 33.39
City/State/ZIP:Tigard OR 97223 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Phone:( ) Fax:( ) Attic/crawlspace fans 23.32
y
•, Other:
� ell.' j �'�/i� � ,. a ,. ,/-� # / � 23.32
Business name:Brazing Gyro's Fuel iping:
$14.15 for first four;$4.03 for each additional
Contact name:Mike Furnace,etc.
Address: 138 SW Pacific HWY Gas heat pump
Wall/suspended/unit heater
City/State/ZIP:Tigard OR 97223 Water heater
Phone:(503)957-9955 Fax::( ) Fireplace
Range
E-mail:
Barbecue
..z . #. Clothes dryer(gas)
Business name:Huse rSales And Service Inc Other:
Address:231 N Tillamook St , , f„ °G ,\' g �
Subtotal
City/State/ZIP:Portland OR 97227 Minimum permit fee($90.00)
Phone:(503)248-1948 ii Ar, Fax:(503)248-7077 Plan review(25%of permit fee)
State surcharge(12%of permit fee)
CCB lic.:116821 c)9 01.../ TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
`i„11.40 U t- days after it has been accepted as complete.
Authorized signature: * Fee methodology set by Tri-County Building Industry Service Board
Print name:Daniel Krahn Date:7/27/2016
I:\Building\PermitsUlECPermitApp 040113.doe 440-4617T(11/02/COM/WEB)