Permit •
CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: MEC2012 -00600
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 11/20/2012
Parcel: 2S114BB08900
• Jurisdiction: Tigard
Site address: 16264 SW 104TH AVE
Project: Capper Subdivision: SWANSON'S GLEN Lot: 30
Project Description: (1) gas furnace
Contractor: GAROKEN ENERGY COMPANY Owner: CAPPER, PATRICK D
• 3565 SW 182ND AVE 16264 SW 104TH AVE
BEAVERTON, OR 97006 TIGARD, OR 97224
PHONE: 503 - 848 -3838 PHONE: 503 - 956 -2976
FAX: 503 - 356 -9002
FEES
Specifics: Description Date Amount
Furnaces < 100K BTU 11/20/2012 $46.75
Type of Use: SF 12 %.State Surcharge - Mechanical 11/20/2012 $10.80
Class of Work: ALT Type of,Const: Minimum Fee Adjustment - Mechanical 11/20/2012 $43.25
Occupancy Grp:
Stories:
•
Fuel
Fuel Types:
Gas Pressure:
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•
• Total $100.80
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Required Items and Reports (Conditions)
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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 questions to OUNC by calling 503.232.19 or 1.800.332.2344.
Issued By: fib ��vlJC.t,la At- Permittee Signature: O Li e A 'v,
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.
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NOV-19-2012 15:53 FROM:GARa s. T0:5035981960 P.1
V ED 33569oe2
Mechanical Permit ApplicatiRo I.OI( (►1:i.-1(I.: I:..' l (t,VI.,.
City of Tigard Y 2042 - Received
Date/By. l � at, (, . Permit No /41,01 i t .- Q D4a
13125 SW HaII Blvd., Tigard, OR ' r}-►; t • 1 Plan Review
tt: Phone: 503.639.4171 Fax: 50315981 •. I! f , '
r . y
I , - , �� : Other Permit:
1 ,,, . .,..„ Inspection Line: 503.639.4175 "JI ;.I .:0!, 'Il 'i !;.'.II
• { Date Ready/By: curia See Page I for
Internet: www.ligard Notified/Method: Supplemental upplemental Information
�
•. : , - , 0 Q**��`'. St.ii3D11.[ai.4SE:CN>13tfQifT
Mechanical permit fees* are based on the value of the work
❑ New construction gAddition/alteration/replacement
Demolition performed. Indicate the value (rounded to the nearest dollar) of all
❑ Other: mechanical materials, equipment, labor, overhead, and profit • ? -, ,' °_• . .(�lA' (;0117�?''OI±'fi0kiffitUG ►IlSN . . i • • Valu S
. " ' ,, - - -
- and2 -f (Ri?.9m8Y1;1A1.�FQM1`r!$1hL9 ;;
Y dwelling ❑ Commercial/industrial 0 building
❑ Multi For special information use checklist.
Y ❑ Master builder ❑ Other:
Description P Qty. I Ea. I Total • JOB; 9rFE INFORMATION AND I;OCATION Heating/cooling
Job site address: ' 2//-- 1. f O n n Air conditioning
rP 1 t7 �•7 (requires site plan showing placement) 46.75
City /State/LIP: .71. a v � C M a a e :Fum� 100,000 BTU (ducta/vemaT ' 46.75
Suitelbld ./ t. no.: `/ Furnace 100,000+ BTU (duos/vents) 54.91
!; aA Project name: A n (` Heat pump °� P P 61.06
Cross street/directions to job site: Duct work 23.32
` _ ,, - Hydronic hot water system 23.32
$t.S.4 Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Subdivision: I Flue/vent for any of above 23.32
Lot no.:
Other: _ 23.32
Tax map/parcel no_: Other fuel appliances •
DE W ' Water heater 23.32
/1_� Gas fireplace 33.39
(' 7 LUx Flue vent for water heater or gas
fireplace 23.32
Log lighter (gas) 23.32
- Wood/pellet stove 33.39
Wood fireplace/insert 23.32
• P1L Y RIY. cam R:,7 .: ' I' Q . ririorr -
Chimney/liner /flue/vent 23.32
I - - - Other: 23.32
Name: EA ; r i / (^ �,
. "1'J (`.rte N( Environmental exhaust and ventilation
Address: I_,-,' V' Range hood/other kitchen
Sebw�.�y ec 5 ct b Q equipment 33.39
City/State/ZIP: Clothes dryer exhaust 33.39
Single -duct exhaust (bathrooms,
Phone:
( s/2? Fax: ( ) toilet compartments, utility rooms) 23.32
'4' :7A'PELst_ C KCONI'AGL r I$oN.,; Anic/crawlspace fans 23.32
Business name: G Q,Y0 1/ I Fuel 23.32
1� � Fuel piping
Contact name: N ti.t. a Co Ne \ $14.15 for first four; 54.03 for each additional
Address: oce Furnace, etc.
Gas heat pump
City/State/ZIP: Wall/suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater
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Fireplace
E - mail: 4&' o key, e.V.ev- g` s Q u ev t z.ovi. n .e-- Range •
• . - . ', CONTRACTOR; - ° - . - . Barbecue •
Business name: �Q. �-o K QN �N�v., �� C.ea Clothes dryer (gas)
Other:
Address: 35 4,5 g lea ^ 1 J
w NIBCHANICAL.PEghtiTFEES!,
City /State/ZIP: ( ■- 1QU e r 4 CA 91 CC Subtotal
Phone: (50- 415. 3$3$ I Fax: ( . r Minimum permit fee ($90.00) CfQ_OO
` 4 U `�.L Plan review (25% of permit fa)
CCB lic.: L{ `a . State surcharge (12% of permit fee) /O. rD
TOTAL PERMTT FEE hod _R7
Authorized signature QL 7Pq C:;:o Tbts permit applitatioo espirea if a permit b aol obtained within 180
d after it has bee acce u eompleta
Print name: Np v%. hr '1- oNcc\..GLt,, j Date: l 1 /16y/ / • Fee methodology set by Tri.County Building Industry Service Board
1:1auildinppemjt\ C•permhApp.doc 10101/09 440 - 461 (II OM/W¢91
Nov. 19. 2012 3:56PM No. 0823 P. 1
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I , 7o20/,e2 '0D` 71 Clean Water Services File Number
'k1 a' ' ' Ne --4/96e° �z - v o w 149 C1ean�'Uatei Services
NOV 16 2012 , . ensitive Area Pre- Screening Site Assessment
1. Jurisdiction: V ' • " ' 1'I L-+.A ') C
Y
ope n ormat on (example 1.9234/1801400) 3. owner Information
Tax lot ID(s); 2S103BC00300 _ Name: Brit Carroll & Laurel Dent
Company: ,
Address; 12180 SW Walnut St,
Site Address; 12180 SW Walnut St. City, State, zip; Tigard, Oregon 97223
City, Stale, Zip: Tigard, Oregon 97223 Phone /Fax: 503 -888 -0889
Nearest cross Street; Walnut/121st E.M brh_carroll@hotmail.com
4. Development Activity (check all Thal apply) 6. Applicant Information
( ' Addillon to Single Family Residence (rooms, deck, garage) Name; BrH Carroll
O Lot Line Adjustment 0 Minor Land PartItlon Company:
Q Residenlial Condominium 0 Commercial Condominium Address: 12180 SW Walnut St
O Residential Subdivision ❑ commercial Subdivision City, State, Zip; Tigard, Oregon 87223
0 Single Lot Commercial P Multi Lot Commercial
Other phone /Fax; 503 -868 -0869
E -Mall: brit_carrolll"a,,�hotmall,com
6. Will the project involve any off -site work? QYes N No ❑ Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
approx 18' extension of exlshing master bedroom Into exlsfting yard ar
This application does NOT replace Grading and Erosion Control Permits, Connection Permits, Building Permits, Slte Development Permits, DEG)
' 1200 -C Permit or other permits as Issued by the Department of Environmental Quality; Department of State Lands andlor Department of the Army
COE. AU required permits and approvals must be obtained and completed under applicable local, etate, and federal lave
By signing this form, the Owner or Ovmer's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority
to enter the project site at all reasonable times for the purpose of inspecting project site conditions end gathering information related to the project site. I certify
that I am familiar with the infomiatic, .. j .Ined In this document, and to the bast of my knowledge and belief, Oils Information Es true, complete, and accurate.
Print/Type Name Brit arrofl f} Print/Tips Title Mr.
�r
Signature / • ..� Date 1 / - g ') 2_ ,
FOR DISTRI USE 0
Q Sensitive areas potentially exist on site or within 200' of the she, THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feel on adjacent properties, a Natural Resources Assessment Report
• d may also be required.
Based on review of the submitted materials end best available information Sensitive areas do not appear to exist on site or within 200' of the site. This
Sensitive Area Pm- Screening Site Assessment does NOT eliminate the need to evaluate and prated water quality sensitive areas If they are subsequently
discovered. This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.02.1. All required permits and
approvals must be obtained and completed under applicable local, Slate, and federal law.
q Based on review of the submitted materials and best available Information the above referenced prolec( will not signiucanlly impact the existing or potentially
sensitive area(s) found near the site, This SenslfiveArea Pre - Saeening Site Assessment does NOT eliminate the need to evaluate and protect additional water
quality sensitive areas it they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order
07 -20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local, slate and federal law
Q Thie Service Provider Letter le nol valid unless CWS approved site plan(a) are attached, x
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C) The proposed activity does not meet the definition of development or the lot was platted after 9/9185 ORS 92.040(2). NO SITE ASSESSMENT OR i
SERVICE PROVI e _ 7 LETTER IS REQUIR • D.
Reviewed by = _,,. M i I -j Date i 1/11A
;.2550 SW FliiIsboro I -li5h /av Hiii uwu .Oregcn 07123 •Phanc (505) 88 t 5 F 'ar(003)'CS 1 44,19 it , v rl aii:y IPrserrR. s pn)
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