Permit Support Document (16) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT '' rt111 �
_ Request for Permit Action 007 „eirr-
TI G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Ni City Staff
Check(1)one
REFUND OR Name: /
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#: N tC x'1017--00 c/g3
Site Address or Parcel#: /O g HE/ibex° A4:30/t �jg, 460
Project Name: Le,WA-413
Subdivision Name: Lot#:
EXPLANATION: 1.3,e, r tAD E .) Li iL MEG 9.017-00 47
/10Gte51)41D—A.)0 'E,,�c� •.
Signature: C ► ' Date: .7/13I1-
Print Name: —1Dos,hi ' /W 4 ka
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date 9 /y` /7 B
Refund Processed: Date ,u1.7,4 By Invoice Processed: Date By
Permit Canceled: Date f//y/j 2 By "ISarcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_012314.doc
1 1ii,
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Mechanical Permit Appl ' • 1 ! EIYEP.1:.41J1 t'Olt OFFICE USE ONI.‘
City of Tigard R...ivca _ /.., (--;...)/),
,
elly: (1/el"'-fia I
'11 13125 SW Hall Blvd.,Tigard,OR 9
itiN 2 8 21)17 Plan Review
Other Permit.
. 6 Phone: 503 71S 2439 Fax: 503 591(1960
Date/By:
.. . .
TW ARD Inspection Line: 503.639.4175 ,e,=.
'PI 1 Y OF TIGARI) Dat ke'ldVItY' Ions: RI See Pagel fur
Internet: wwwligard-or.gov ‘-'
NetificdVethed: Supplemental Information
BIJIL1)ING DIVISION , ,,0 00.,,,,, ._, ., ,.,...,,,L"-_, ,,,,
'el... .. '-. II' fk 41 4. -1'1' li -4; ' '!:-.1P- t 11:':Ct**-1.--4- 3Z. :1:" ..'''''i
,..,, A .s-, , ,- ' *,,t - ---,- 1/4 mechanical permit fees*are based on the value of the work
ElNew construction p4 Addition/alteration/replacement petfatmed.Indicate the value(rounded to the nearest dollar)of all
El Demolition 0 Other: mechanical materials,equipment,labor,overhead and profit.
„.,
; i'l ***-464-10ii:: : #R100* ' --t' 'It- :-.-,,--1k" 't 1,:- fk f..,, *0,,i,- ,:to-*,-. ,14-0, ,i,,.4it- Tq'
0 1-and 2-family dwelling 0 Commercial/industrial 0 Accessory building For ipeeial informer:1nm use checklist
a Multi-family 0 Master builder 0 Other: Description Qty. Ea. Total
fleafi
'Pr 44. :,,,,1, ' .. :;1 ,+,,,,,,Z7,- 0, 1 A if, '1'' If; ttRic001iR : ..
.
Air conditioning - 46.75
Job site address: t 6001% 0 40.1 \r7.4-0.it)Nig,.. Furnace 100,000+DTI)(duets/eats) 54.91
Furnace 100,000 BTU(duetstvents) 46.75
City/State/ZIP: C, c.
.1". 0!
Heat pump 61.06
Suite/bldg./apt.no.: Iroject pante: 1ie,L.;,4),J1) Duct work 23,32
Cross street/directions to job site:
Ilydroltie hot water system 23.32
Residential boiler(radiator or
hydronie) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 23.32
(Ater:
Subdivision:
[Lot no.:
23..32
Other fuel appliances:
Tax map/parcel no.:
Water heater 23.32
-it, Vt ''''kt- 1 " Gas fireplace/insert 33.39
*;*(41*.'.' -'1' =41'; li - Flue vent for water heater or gas
142.....Ct ClorN frCri
kT,k—:\ ci,A.-A. -N • fireplace 23.32
Log lighter(gas) 23.32
Woodipellet stove 33.39
Wood fireplace/insert 23.32
Chilinneyllineritlue/vern 23.32
m.,- aaiiii- iiii ia,*.00ti,,i?ciii Ait,:iiii iifii iii„, 1 i 11 iit,;,--Tt. 71,,s 346,141:41,1,44ii pi A:-,.',, Other: 23'32
tr,..,p,,g—,,,, -,10 ,411k -4,- ,, -,,, , _, , ' 4, , ' Environmental exhaust and ventilation:
,
Ninnet-- g p ft 4_. )44 0 ,..„A 1,3*-7. Range hood/other kitchen
equipment 33,39
Address:
.Clothes dryer exhaust 33.39
city/state/zip; Single-duct exhaust .(bathrooms,
- toilet compartments,utility roams) 23.32
Phone:( ) Fax:( ) Attic/crawlspace fans t 23.32
;Oet.&7--xl.16wEi',':IP '':,'-ic-11'1 --Iti".,. ,:,.,,,::: iii.l..,;-:!'(..-, itH #4064- ,1 -,„::,,.; .Otherdpiping:Business name: 15 for first
four; 4...03ro*r each additional 23°32
,.. 1‘.1
Contact name: Ys/3 y\ i /,...NylkS. Furnace.etc.
• I \L"1/4d
Address: n Pr\ 4
, 1 at
Gas he pump ..
t1:::‘ 64iYV "C (:)%r 1:Vallisuspended/unit heater
City/State/ZIP: ii •AkCa Water heater
) ...*P.1 -
Phone:(StS . j442,,li Siott rS ax::( )3) %..Le t 1,1::), Fireplace
Range
E-mail:4r)ff'I't.k.Q.MSc 64'CriX,NirV4t)etTN.*CON14.1"‘ Barhmtle
, --11:, t fz,,, , Clothes dryer(gas)
Other:
'Business name: C.a5(iCtrst.t •R•C'tC1/44:tr% _,T'tki-.)C II- :i'iit.- -,`iii, .,'" i'la 41.i'„(1.cii,i, ":;''''N''''k't.,1111!*FrS,
Address: y2.1s#30‘ - qor* t.......lcu.rit kli--cl , " Subtotal
Minimum permit fee($90.00) c97‘0
City/State/ZIPei 1,,,t4.,y‘ct 0 q--.) ,,..3(2;„ _ .... . . i ,„
?)........
Plan review(25%of permit fee) ,4 „7
Phone:663)Lt-2,k.t..4,‘61,e17( 1.Fax: 10J Ztt I - 6 ti(-) State surcharge(12%of permit Me) // 9
/
CCI3 lie.: (.466' .--.6.----1 - This permit application eTspOirTmAitLa PERMIT
isrrnotFaEbEtained within 180
,..
--... days after it has been accepted as complete.
Th-County
Authorized signature: Nt * Fee methodology set by Tit-County Building Industry Service Board
Print name: tv„-iy, 5 I Date: ( l'1,-1 1 1-7 ]f
1:111efitInePennitelhAEC_PenrnitApp_040113 doe
440-45171(11/021CONYWER)
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEVI
1
11111 : ill ReV 0 quest for Permit Action 9//Yh7 li.
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor RI City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) /
Mailing Address: r/
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
N. CANCEL/VOIDFUND PERMITPERMITFEES APPLICATION.
RE (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#: H 02 1 7 - c c SD 9
Site Address or Parcel#: 141 ((p S /a 5* A t)ti-
Project Name: (L,ci.1.v...1.2
Subdivision Name: Lot#:
EXPLANATION: ektqTrc7 GJ Qo n)Co 4 .H i T- 11 Y P . .51£. H'rTao/7-00-776
Signature: K _ , Date: ?/3 ii7
Print Name: i46 ft .M4D(S1
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 7 i3 :k Route to Records: Date '` /9' /7 By al''
Refund Processed: Date /V hi By Invoice Processed: Date By
Permit Canceled: Date 9// V/7 By,caly Parcel Tag Added: Date By
I:\Building\Forms\RegPernutAction_ 92314.doc