Permit Support Document CITY OF TIGARD MECHANICAL PERMIT
IN-0- q Permit#: MEC2019 00617
'' COMMUNITY DEVELOPMENT
" � ,. ; Date Issued: 08/21/2019
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 " Parcel: 1S125DA00501
WAINJurisdiction: Tigard
Site address: 9150 SW 66TH AVE
Project: Shepherd Subdivision: None Lot: None
Project Description: extending gas line and installing a gas insert. 9/17/19:REPRINTED permit to remove(1)gas line extension for the
range.
Contractor: FIRESIDE CONTRACTING SERVICES LLC Owner: BROWN,VAUGHN D&MELISSA SHEPHE
18389 SW BOONES FERRY RD 9150 SW 66TH AVE
PORTLAND, OR 97224 TIGARD, OR 97223
PHONE: 503-684-8535 PHONE:
FAX: 503-620-5699
FEES
Specifics:
Description Date Amount
Gas Fireplace 08/21/2019 $33.39
Type of Use: SF Fuel Piping 08/21/2019 $14.15
Class of Work: ALT Type of Const: 12%State Surcharge-Mechanical 08/21/2019 $10.80
Occupancy Grp: Minimum Fee Adjustment-Mechanical 08/21/2019 $42.46
Stories:
Fuel
Fuel Types:
Gas Pressure:
Total $100.80
Required Items and Reports(Conditions)
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 503.232.1987 or 1.800.332.2344. a
Permittee Signature: e`�-�=f' /
Issued By: /� �`_
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.
City of Tigard ' COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
T l Ci 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 2 Contractor ❑ City Staff
Check(✓)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):
El 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#: E c a cAok- ty3 k4 I-1
Site Address or Parcel#: C1 t O Ej1,J \o.1 prJ
Project Name: S1R.o 1t't
IL
Subdivision Name: Lot#:
EXPLANATION: ''cc AA -" 'OA- (p V0, COROSVect op IvAk U4101 btitl-1
' -kt ' , I . +'1 t if i' . ItILJ X' 0 1 ,'// ° •
1>f IIk tr►1 1h l<1t A .A / Al I le. l ! it Si 4 )P t. ILA cr.
50 CO- elV\6.r C1 •• ' ,t . ,✓ Ic O -
ignature: / 1 1 i Date: 1 \ Ot
fir.,f r, . vv'r� prior
Print Name: V sct,6j
' ` 46414 64,4 sph l
Retina Poitcj' Y
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 sI/i-,/,ti By,0 Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Buildin g\Forms\RegPermitAction_120518.doc