Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
111111 Request for Permit Action PL-/-7//f-
44/
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 p Applicant p Contractor )3ty 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 (✓):
O 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).
Permit#: /t7Ce01 —®0 of 3
Site Address or Parcel#: 9 ..S'A 4/6,..(6.77-4,/ - //--o
Project Name: 2)//1/ 729/ /ir/62--
Subdivision Name: Lot#:
EXPLANATION: -Ge/04=r C__f-r 0e X47/ Sc.(f,(.7'// -K-2 7.
a0i07 z�-. - .5' ' .i�r-- /F-- CSD S"g /,�. rnie_.
C6A-7/'t n
Signature: A/77491—e---- Date: /2,"//d'
Print Name: / /A/if l'e07-i---CE—
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /O. 7 / By
Refund Processed: Date ^//,9 Invoice Processed: Date By
Permit Canceled: Date/z17 AB reel Tag Added: Date By
I:\Building\Forms\RegPemutAction_1 51 . oc
RECIN/Fr.
Mechanical Permit Application
Foi ouivity l sE oNl,v
JUN 2018
City of Tigard Received
Date/By: dr , '` Permit N9/1-.),6--e,,20/./...ex
2,2
"
It v 13125 SW Hall Blvd.,Tigard,OR 97223 crry n c.. r i A.ri(' Plan Review n
Phone: 503.718.2439 Fax: 503.598.1 i6A ii
b
r ,t'.csI r ateBy: Other Perm �/ A --a i/
\17)!
1 ( ARi) Inspection Line: 503.639.4175 °- a �� i ate Ready/By: Juris: 0 See Page 2 for
Internet: www.tigard-or.gov it Notified/Method: Supplemental Information
Sqlrili, �z � a.. ,",,,,,,':. >,"s'�' x a7 l ' �L FEE" b13`L'7 ' E CHECK IST
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"` ��" 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:$
",. ;+,{;r„ x;'k-"vj"%,,;:';,;m a,' . , ,r.,..,v.,.,..: y ,'sa.;;;," Mc.`�=°,,; ...., y,as;- (/'� /A/ I' 0,4
, ery
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,, . ,,�, .. . ...., ;� .� .,�,.:,, ;x" . �. :.; ,k e�i���t�tr �t'> s'r��Is1F'�
0 1-and 2-family dwelling ®Commercial/industrial ❑Accessory building For special information use checklist.
❑Multi-family ❑Master builder ❑Other: Description Qty. Ea. Total
:. i , ,� Heating/cooling:
� ��t�B SITt��'�IZMATIo � LiS �'CII�� ��`"���� � '�.
, t ..... . ...... .. D ....,, ,�
Air conditioning 46.75
Job site addresw Washington Square Road Furnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP:Tigard,OR 97223 Furnace 100,000+BTU(ducts/vents) 54.91
Heat pump 61.06
Suite/bldg./apt.no.:F06 Project name:Din Tai Fung Duct work 23.32
Cross street/directions to job site:NEAR SE CORNER OF MALL,NEAR MAIN MALL Hydronic hot water system 23.32
Residential boiler(radiator or
ENTRY TO SEARS 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: Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.:1S126CC00100 Water heater 23.32
," k °: tfD CoRwr1N o o " ;ice , ", Gas fireplace/insert 33.39
...
Flue vent for water heater or gas
Work includes demolition and tenant improvement for a new restaurant. fireplace 23.32
Interconnecting supply,return,exhaust ductwork(including toilet,..t p.1-and Log lighter(gas) 23.32
Wood/pellet stove 33.39
type 2. (5)RTUs by others. Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
�` ,:
Other: 23.32
i';'''''':''''''5.54 � ',�UPEI��o'Y(VL,'R ....,."��� a`",.. ev= ,',5.,:;;;,;,:e.,,... ,. .- .a�.. :.
" -" Environmental exhaust and ventilation:
Name:DAVID WASIELEWSKI Range hood/other kitchen
equipment 33.39
Address:700 BELLEVUE WAY NE,SUITE 280 Clothes dryer exhaust 33.39
City/State/ZIP: BELLEVUE WA,98004 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Phone:(206)953-0770 Fax:( ) Attic/crawlspace fans 23.32
t4141501040:410601.:(1.4 :+. .,i,:ii.: �Q coNtACT FERSO* ; I Other: 23.32
Business name:CHIN-LEY/RECHE ASSOCIATES Fuel piping:
$14.15 for first four;$4.03 for each additional
Contact name:SERGIO CHIN-LEY Furnace,etc.
Address:1516 MELROSE AVE SUITE 200 Gas heat pump
Wall/suspended/unit heater
City/State/ZIP:SEATTLE,WA 98122 Water heater
Phone:(206)769-8601 Fax: :( ) Fireplace
Range
E-mail:CHINLEYRECHE.COM Barbecue
Clothes dryer(gas)
::usiness name:TBD Other
't MEC(HA ICA,IL PL 1MIT FEES*s v,v... iv
Address: " Subtotal
City/State/ZIP: Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:( ) Fax:( ) State surcharge(12%of permit fee)
CB the `; TOTAL PERMIT FEE
p, j V r p,,,' ', 't. ,x 9,-�„ a" This permit application expires if a permit is not obtained within 180
Vit.. c -�r :
days after it has been accepted as complete.
Authorized signature: �+"""" * Fee methodology set by Tri-County Building Industry Service Board
Print name:SERGIO CHIN-LEY Date:04.30.18
I:\Building\Pemuts\MEC_PermitApp_040113.doc 440-4617T 0 1/02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial& Multi Family Fee Schedule:
Tb1`al Valuati "Nitro rtrtot Fees
$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
$5,000.00.
$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.
I:\Building\Permits\MEC_PermitApp_040113.doc 2
Af'ZC a DELIVERY NO. 1541014
2730 Occidental Ave S
Seattle,WA 98134 ,'` ? DATE 06/01/18
206-622-6000 � _ �'—
30 2_518 WO# 5326420
o DELIVERY TICKET o Contact#26000
H , tpl �¢�p qj:4 a ATTN: Bldg Division
o iShipdocs - { � �� (�p City of Tigard Permit Center
13125 SW Hall Blvd.
Tigard, OR 97223
11111111111111111111111111111111111111111111 JOB DUE: 06/04/18 at 17:00
CONTACT PHONE PURCHASE ORDER# SALES REP
Sergio Chin-Ley/CHIN-LEY/RECHE AS (206)938-1501 Lamar Middleton
JOB# JOB NAME BILLER LOC
DTF WA SQ DTF Washington Square Christine Warnock 052
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., P QCI _.,. t a ; `F F.R,I sT10 i A s e., f srss QRlGrNAts..„p,r,m ,.is/ s ° `::.;NITS s 1 T x A*6014
SUB TOTAL DISCOUNT SALES TAX TOTAL DEPOSIT BALANCE DUE
TERMS: