Permit CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: MEC2009 -00614
TLGAR.D; 13125 SW Hall Blvd., Tigard OR 97223 501639.4171 Date Issued: 11/17/2009
Parcel: 2S103CA00203
Jurisdiction: Tigard
Site address: 11820 SW JAMES CT "
Subdivision: Lot: 0
Project: Dameron
Project Description: Install gas line to range.
Owner: FEES
DAMERON, ROY Description Date Amount
11820 SW JAMES COURT
Fuel Piping 11/17/2009 $14.15
TIGARD, OR 97223 12% State Surcharge - Mechanical 11/17/2009 $10.80
PHONE: 503- 524 -3982 Minimum Fee Adjustment - iMechanical 11/17/2009 $75.85.
Contractor:
COLUMBIA HEATING & COOLING INC
PO BOX 230397
TIGARD, OR 97223
PHONE: 503 - 624 -2704
FAX: 503 - 598 -0270
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Fuel
Fuel Types: Natural Gas
Gas Pressue:
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 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling'503.246.6699 or 1.800.332.2344.
Issued By: ` Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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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17 09 11:27a Columbia Heating/Cooling
503-598-0270 p.2
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Mechanical. Petriiit ApDhcat t 1, , ;
,
c,ity of Tigard . Received 97223 NOV 17 2009 ,_ Perna No
• ' ,,•• '''‘'!;‘:-- ° 1,312::5 SW Hall Blvd., Itgat4., PI t ' r-)--IBY' ..A Devic2cO__q_=icia_C2_4 . '•
Plan Review
phu,ic 503 s19 4 )71 Fax: 503.54.1960i Dbtell3y. . Otion PerfTlti.
1,ine: 503.63
AliG ARO 9:4175 * 'CITYOF TIGARD Date Reoidy/By: . 3 r.!;. fil See 'rate'? Jot
Sopplem'ental lytitignation i
' 'Notified/Method:
BUILDING DIVISION - • .
- - .
TYPE OF WORK COMMERCIA 'FEE scukEDITLF, - tssvcinttuAsT .
. __
Mechanic:al permit fees* are basedlin the value uf the work
F E I hew ennstniction 5-•Ifdclitionialterationkeplaccment performed. indicate thc value (teunde.d:to tile nenicaf dollar) r, f all i
[j] flibrnnlition 0 Other . mechanical materials, equipment. labor, ovcrilcad, and Pori
. .
CATEGORY Value:3,
ORY OF .CONSTRUCI
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
El 1 - and ")-family dwelling 111 Commercial/industrial 0 Accessory building For speck?! Igformarion um checkhst.
0 Mufti-family E Master builder D Other: Description Lpt ii.a. i Total
.
JOB SITE INFORMATION AND LOCATION • Heating/co-dim
Air conditioning . •
Job s;tc address: I I gio 5 .1 i (requires.sitc p)ar snowing placement) 46,75
Furnace 100.000 BTU (ducts/vents) 46.75
Citl.•"Statc - 1 - i_.,( 9 c7z2-) Fun 100,000 BTU (ducts/vents) 54:91
SuitelbldRiapt. no. Project name: _Heat pump 61.06
-
Cross street/directions to jeb site: Duct work 23.32
Hydronic hot -water system 23.32
Residential boiler (rad)ator or
hydronic) 23.32
Unit heaters (fuel-type, not electric),
in-wall, in-duct, suspended, etc. 46.75
Flut/vcnt for any of attewc 23.32
Subdivision: Lot no:.
. • .- Other: 23.32
Tax maptparcel no.: Other fuel appliances
DESCREMON OF WORK • • Water heater 23.32
_Gas fireplace 33.39
Flue vent for water heater or gas
fireplace 23 32 -
Log lighter (gas) - 3 32
[---- . Wood/pellet stove
33.3
Wood fireplace/insert , e,
23.32
Chimney/liner/flue/vent 23.32
PROPERTY OWNER j 0 TENANT , .
- Other: 23.32
Nam:: --- po
i / • 1._ triiii ei'd ici;
, -----/-), i Environmental exhaust 2 nd ventilation
Range hood/other kitchen
Address; 52 5 j -
../.;-- :Quipmcnt 33.39
Clothes dryer exhaust 33.39
-
City/State/7.1P: - O a. 14- f
Single-duct exhaust (bathrooms,
Phone: (•7 ) 5-2 79.4 Fax: ( ) toilet compartments, utility rooms) 23.32
0 APPLICANT 0 CONTACT PERSON Attiderawlspace Fans 23.32
Other: 23.32
Business name:. ' Fuel piping
Ciontact name: /)') /...-- 1 1:,-e it0
-2 /2")-e(
a S14.15 for first four; $4,03 for each additional
• ' Furnace. etc.
Address: Gas heal pump 1 ___I
l.iitiStateiZIP: Wall/suspended/unit beater I
.. 1
e-.. iii.• Water heater •
Phone: (.51,3) 0 , 7 ,2 . I d. 0 V. C oi•
, Fax: : cx -- 5 ,S , - - / .
Fireplace
F-mail: __ Ran.e 1 1 I
__v
CONTRACTOR • Barbecue
1---- , .
a _
,
flusincss. name: i la 1. .._ a imu : zar , A Ana dik ,.. Other: Clothes dryer (gas)
..
I :
• Address. ) 0 Ai . . _ MECHANICAL PERMIT FEES*
1 ..... ,... •
1 _ City/Stale/7:11'1 ! al, 7e. r , Minimum p ermit fee ($90.C1(1) LIG . 00
I I runlet 6E13 ) I , , ....Q.7 0 Fax: (5?3) 59 e; - (Jta7D
Plan review (25% of permit fee) 1
CCIII li •
- 7(0 ZE-9 • State surcharge (12% of permit fcc) $ , 6 :, 0
TOTAL PERMIT FEE
This permit application expires if a permit Is not obtained within tin
Authorized signaturyj _ -or A ApApi days after it bas been accepted as co mple ie.
.... if
Print name: /AA 4. 0 i f Ala Date: „ 1 . 1 . Fee methodology set by Tn-Coonty 1111ilding Industry Se 5.ice 3oar
..r, ..,:_..-,..-;,,%cirr..n.00lii A no coc 1 0/0 009 440-4617r t i 1n2,corwsvt0h) . 4 2
Q00 I se- 4 eAtir\ e-OP[cr` .
. ok-ec-eoq -6660 i
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Columbia Heating & Cooling DATE: 12/11/09
P.O. Box 230397
Tigard, OR 97281 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 176033 Case #: MEC2009 -00614
Date: 11/17/09 Address /Parcel: 11820 SW James Ct.
Pay Method: CreditCard Project Name: Dameron
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee • Example: 245- 0000 - 432000 • $ Amount
Mechanical Permit Fee 2300000 -43102 $72.00
12% State Surcharge 1003100 -24001 8.64
TOTAL REFUND: $80.64
APPROVALS:
If under $500.' Professional Staff ZaSZ(9--"VV\--
If under $7,500 Division Manager
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: , y 3 11 j ' ` ` By: I '1
, -
°-
—? % B y:
1 - :
Case Refund Processed: Date:
1: \Building\ Refunds \RefundRequest.doc 04/13/09
" - Dec-01 09 03:14p Columbia Heating /Cooling 503- 598 -0270 p.1
RECEIVED /1, 260 -- L) 6 l 4
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71
, .-
,s3 Y DEC 02 2009
La Community Development
CITY OFTIGARD Request for Permit Action
T ;cnk ° BUILDING DIVISION q
TO: CITY OF TIGARD
Building Division Services . Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.398.1960 wv.w.tigard or.gov
FROM: ❑ Owner n Applicant 11 Contractor n cit Staff
(check one)
REFUND OR Name: ^.
INVOICE TO: (Business or Individual) ow 07 it a_ i : �� - � 6._, °F•-- CoOi IJG
Mailing Address: /61,0 c letqe aaCIZCi 7
City /State /Zip: 77 --R. 0 CA q7Q 1
Phone No.: 03 ( Li -• a 7D'-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
P REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CON I KACTOR � FRO / M P R ERMTT (do not cancel permit).
1 ° E .
Permit #: .! I - / 4
Site Address or Parcel #: 1I Q e,S oviR3----
Project Name: si -j4 iQ
Subdivision Name: Lot #:
EXPLANATION: (' cT f2- ent )(VGI 0
Signature: A . ` , ./ / l ll t Date: 1 Q- . 1-0'9'
Print Name: /J , ,a . lif'9 * i
itvfund Policy
1. The Director or Building 1)fficial may audio; ze tile rc .Ind of:
a) any xe which was eironcously rid or collected.
1s) not more than 8■`%0 of the land use application fee when an application is withdrawn or canceled before any re iw effort has b_en espunded.
cl nc[ mun• ti 80 °., rot rhr innd u:c aPpticrrian Fee Fnr sued 2crnuts.
c) not more than 8J °-- of the'_uildtng p'.an review fee when .r. application is canceled before anv plan review effort h: _ii' :;err. expended.
e) not pore than IiU° of the building permit fee for issued permits prior to any inspection request.
2. Refunds will be returned to the original Payer in the same method in which payment W35 :eccived. Please ailcw 1 -2 weeks for processing refunds.
z t,•, t's, - ' :,,it ta, lr k_ • ani tgri Or'r 0i SL QNK s. !I:4- i'`, • : ?';, : IP.
Rte to Sys Adtnin: Date By Rte to Bldg Adtnin: Date 4.1/4,9? By !A
Refund Processed: Date/ By Invoice Processed: Date By
Permit Canceled: Date / By '" Parcel Tag Added: Date By
Receipt # Date Method _ Amount $
I: \Huiidiny \Forms\ Roil PcvnitAction.doc Rev lJ7 /do /07
•
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City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
III
December 11 2009 , ;`
Columbia Heating & Cooling
P.O. Box 230397
Tigard, OR 97281
Attn: Marlena Meedom
Re: Permit No. MEC2009 -00614
Dear Ms. Meedom:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 11820 SW James Ct.
Project Name: Dameron
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $80.64.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
...c:
.. �-t, ;.,.....,/,
% fir
Dianna Howse
Building Division Services Supervisor
Enc.
1: \Building \ Refunds \ Administration \LtrRefund-CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard - or.gov • TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
n
lIlIl a 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Al c- i i L
Receipt Number: 176278 - 12/11/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2009 - 00614 $ - 80.64
Total: $ -80.64
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 617104 DHOWSE 12/11/2009 $ -80.64
Payor: Columbia Heating & Cooling
Total Payments: $ -80.64
Balance Due: $80.64
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1111 CITY OF TIGARD RECEIPT
q
m . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TI GA1tn
. f) N' , f
r
Receipt Number: 176033 - 11/17/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2009 -00614 Fuel Piping 2300000 -43102 $14.15
MEC2009 -00614 12% State Surcharge - Mechanical 1003100 -24001 $10.80
MEC2009 -00614 Minimum Fee Adjustment - Mechanical 2300000 -43102 $75.85
Total: $100.80
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 617104 LSELLERS 11/17/2009 $100.80
Payor: Columbia Heating & Cooling
Total Payments: $100.80
Balance Due: $0.00
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