Permit Support Document (30) V
City of Tigard • COMMUNITY DEVELOPMEI EPA T
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TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tiga c1Par.go °`
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: p Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: / ,[
INVOICE TO: (Business or Individual) ,.L-(6 r ia, zoo Ae j,� ,1 C o`/J <?tirti6✓ /`,6/j2
Mailing Address: ???P?P �—, i t-t,ovi 67%
City/State/Zip: Sof IJNfe 1)uy�t. J (/Vr, -531 ? 7
Phone No.: ‘,2612 .D1 0.2 7'
,69
PLEASE TAKE_ACTION FOR THE ITEM(S) CHECKED (1):
w.,_..
CAN.CFL- ID 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#: r\C\EQ_ G- 3v y-
Site Address or Parcel#: (- 1 S'yl} \,&Q,iNt „� �,; � , y24 . NA-
Project Name: -kLk;CX) cZ
Subdivision Name: Lot #:
EXPLANATION: : V'�CYLy,_.. -,it • ' ,:y2 k , Nott.., •(
L4 GkiS�.. .- r\ _ rt- c -i . tar\ .�s.ACa Cs<L#c
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Signature: Date:
Print Name: -U M fic> L . `s e VYI _
lte}urid 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 - \pct By T .)-9Route to Records: Date 9 /? B
Refund Processed: Date N By V Invoice Processed: Date By
Permit Canceled: Date -7 /// By, Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 518.d6c -.
V 0 l a
Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard Received Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223Erl
Date/By: `�3/ / frip-Gjy -�) .�j�/
Plan Review s/ Other Permit: �+ `- E
Phone: 503.718.2439 Fax: 503.598114
.19 �� Date/By: 3- 1illti-rt/ j )�(1
TIGARD Inspection Line: 503.639.4175 Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov 9 k `,C\B Notified/Method:ti�,'/i Supplemental Information
.1:,'1 O PJRS.k . �E «.etr a;CH IS ' ''''
, Z ,-.,.:-:::1,:',' -':', e i Or-:' r �t'r Mechanical permit fees*are based on the value of the work
�I Q/3/\1 performed.Indicate the value(rounded to the nearest dollar)of all
❑New construction Addthon/alterafts�> t mechanical materials,equipment,labor,overhead,and profit.
❑Demolition ❑Other: Value:$ Al t.I :J kSl-
CITE ORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT/ IS FEES*,
❑ 1-and 2-family dwelling 11 Commercial/industrial ❑Accessory building For special information use checklist
❑ Multi-family ❑ Master builder ❑Other: Description I Qty. I Ea. I Total
JOB'SITE INFORMATION AND LOCATION
Heating/cooling:
Job site address:„ r Std w.f'( `--tt h • ' Air conditioning 46.75
City/State/ZIP: 74►'z4v,,+.4. C,/--i a-fftP-rD q-4--2:2-3 X23 Furnace 100,000 BTU(ducts/vents) 46.75
Suite/bldg./apt.no.: t N 1 Project name: ' 1.- ALtrik.-_ Furnace 100,000+BTU(ducts/vents) 54.91
Cross street/directions to job site: Heat pump 61.06
t i r l Ti+• lti ,6.--h\ Duct work 23.32
thu
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tt. � ;'
� � / Hydronic hot water system 23.32
1Y-00.VLA 644 gViriii4 4-i . Residential boiler(radiator or
hydronic) 23.32
Unit heaters(fuel-type,not electric),
Subdivision: ULWit- --1VC1.-014 1 Lot no.: in-wall,in-duct,suspended,etc. 46.75
Tax map/parcel no.: Flue/vent for any of above 23.32
DESCRIPTION OF .WORK - Other: 23.32
existing HVAC system to remain no changes.Existing main act trunk and branches Other fuel appliances:
to remain,diffusers to be modifed from a ceiling mount to an open ceiling, Water heater 23.32
Gas fireplace/insert 33.39
flex duct to be removed and new connection to existing hard duct for side Flue vent for water heater or gas
diffusers fireplace 23.32
D '' EATY OW1 R� r TENANT -
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Name: . 1---c) .ts LI I w�--C..
Address: AWood fireplace/insert 23.32
��O W r 1-" .1
Chimney/liner/flue/vent 23.32
City/State/ZIP:
Other: 23.32
Phone:( titftZC� Fax:( )
Environmental exhaust and ventilation:
PPLJICANT CONTACT PERSON Range hood/other kitchen
K
equipment 33.39
Business name: 42x5. 6..� L.r�. j�I
cus
` ` I'L Clothes dryer exhaust 33.39
Contact name: l�`}J! - Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Address: .3,0 t 4-0lk.4 IN) _ 12)/---
Attic/crawlspace fans 23.32
-
-Lty�LSYxtclZlP: ___ _ - ..:_w ,.- -= � _
Other: 23.32
Phone:IESCID SSc (QL4 \ Fax::2 () �`-4,.(:2k22 Fuel piping:
E-mail: f:kT"'_� -,f2_,A` ,---5 a O x '/� $14.15 for first four;$4.03 for each additional
CONTRALTO Furnace,etc.
Business name: -r-r- to Gas heat pump
Address: Wall/suspended/unit heater
City/State/ZIP: Water heater
Phone:( ) Fax:( ) Fireplace
CCB lic.: Range
Barbecue
Authorized signature: Clothes dryer(gas)
Print name:
1G Date: I"I it ( 1 Other:
''MCHANICALT'E'12MIfFEES* r'
1:\Building\Permits\MEC_PermitApp_040113.doc 440-46171(11/02/COM/WEB)
• Subtotal
Minimum permit fee($90.00)
Plan review(25%of permit fee)
State surcharge(12%of permit fee)
TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Fee methodology set by Tri-County Building Industry Service Board
I:\Building\Permits\MEC_PermitApp_040113.doc 2
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi-Family Fee Schedule:
Total valuation: Permit fee:
$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.
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I:\Building\Permits\MEC_PermitApp_040113.doc 3