Permit �.' 4 { CITY OF TIGARD MECHANICAL PERMIT
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`0!'0 ' " COMMUNITY DEVELOPMENT PERMIT #: MEC2007 -00444
�TtGARD. 13125 SW Hall Blvd Tigard, OR 97223 503.639.4171 DATE ISSUED: 7/20/2007
��+'° g PARCEL: 2S110AB -05200
SITE ADDRESS: 14155 SW 114TH AVE ZONING: R -4.5
SUBDIVISION: HAWK MEADOWS LOT: 005 JURISDICTION: TIG
PROJECT: CARLSON
Project Description: Gas line to range and barbecue.
CLASS OF WORK: ALT FLOOR FURN: EVAP COOLERS:
TYPE OF USE: SF UNIT HEATERS: VENT FANS:
OCCUPANCY GRP: R3 VENTS W/O APPL: VENT SYSTEMS:
STORIES: BOILERS /COMPRESSORS HOODS:
FUEL TYPES 0 - 3 HP: DOMES. INCIN:
NAT 3 - 15 HP: COMML. INCIN:
MAX INPUT: BTU 15 - 30 HP: REPAIR UNITS:
FIRE DAMPERS ?: 30 - 50 HP: WOODSTOVS:
GAS PRESSURE: 50 + HP: CLO DRYERS:
FURN < 100K BTU: AIR HANDLING UNITS
FURN > =100K BTU: <= 10000 cfm: OTHER UNITS:
> 10000 cfm:
GAS OUTLETS: 2
Owner: FEES
JENNY CARLSON Description Date Amount
14155 SW 114TH AVE.
TIGARD, OR 97224 [MECH] Permit Fee 7/20/200i $72.50
[TAX] 8% State Surcha 7/20/200 $5.80
Total $78.30
Phone: 503- 624 -9540
Contractor:
RAYBORN'S PLUMBING
19990 SW CIPOLE RD
PO BOX 69 REQUIRED ITEMS AND REPORTS
TUALATIN, OR 97062
Contact #: PRI 503- 692 -4139
FX 51;3- &V. 13
Reg #: LIC 87852
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of Ore. Specialty Codes and all other
applicable laws. 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 than 180 days. ATTENTION: Oregon law requires you to follow rules adopted in the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these
rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued B : P ermittee Signature: d
Y
Call 503.639.4175 by 7:00 a.m. for inspections 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.
Jul. 19. 2007 11:25AM Rayborns Plumbing No. 5774 P. 3
+ n><ca� rermit Application r: ' +' .i ,,, ,� I, ,k - ) R : , ,r . , ,1
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City of Tigard t : 7 Received' t ii D Permit No,: I 13125 SW Hall Blvd,, Tigard, OR 972 , r c . y D 7 I �� pp
Phone: 503.639.4171 Fax: 503.598.1 60 ;� a 1,
Play= Review
J 1 9 2007 � ,, *• ° '1 ' iT q ' ljj I � Date/By, Other Permit: Inspection Line 50 3.639.4175 a , 1 1 L: Data ReadyBy: See Page
Internet. www.ci.tigard.or.us aQ 2 for
„ � � �D
Notified/Method: Supplemental Information
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❑ New construction Addition/aReration/replacement Mechanical permit fees' a re based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other
mechanical materials, •.�, �, ,1,m ,r r materials, equipment, labor, overhead, and profit,
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❑Multi family 0 builder For special information use checklist.
❑ Other: V:141 , z ? , -r c t + � c a a t crt z a r tiT r y t Description Qty. I Ea. 1 Total
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Job site address. l (-0' S S /7 .,7K Air conditionng or heat pump
� ! J l {r site pl showi place I 14.00
City /State /Z1P: ey 4 z Funiace 100,000 BTU (ducts /vents) 14.00 ��
Furnace 100,000+ BTU (ducts/vents) 17.90
Suite/bldg. /apt. no.: 1 Project name: Gas heat pump 14.00
Cross street/directions to job site ` S Gv ` ,h / Cs -- 6 Duct work 14.00
l� Hydronic hot water system 14.00
Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, Suspended, etc. 10.00
Subdivision: Lot no.:
Flue /vent for any of above • 10.00
Others 10.00
Tax map /parcel no _ Other fuel appliances
U J r t ift. { i'E' } '38 �iti9';';'':7iiS it i7rPi}', r t' '� 1 , N Water heater I 10.00
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re-A -1„ l Gas fireplace 10.00
1 / y (/"u 4 e � Flue vent for water heater or gas
V fireplace 10.00
Log lighter (gas) 10.00
Wood /pellet stove 10.00
Wood fireplace/insert 10.00
£ ++ tX 'rte C ,# t , Ta?-I y -ZC tr , t > : Cltimneylliner /flue/vent
+ 10.00
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Name: ` 1
Environmental exhaust and ventilation
Range hood/other kitchen
Address. / - /5 S (_ /I t iA' ,v . equipment 10.00
City /State /ZIP: '-7-/rCc�..) 04 � ZZ2 Clothes dryer exhaust 10.00
�, Single -duct exhaust (bathrooms,
Phone: ( S - ) CZ �, / S er Fax: ( ) toilet compartments, utility rooms) 6.80
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fans 10.00
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Othef: 10.00
1 .� Fuel piping
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Contact name: 11 • /` -_At . $5.40 for first four; $1,00 for each additional
Address: PO Gas heat at pu
- 4tx 6 ! a J
s�- p� / Gas hemp
City /State/ZIP: �,L -J “CA tit 1 V R 9 Wall/suspended/unit heater
Phone: (513) 6 '..-...) - / 3 - ( )/. 3)g Fax: : 33.g Water heater
Fireplace
E -mail: /71 ,• ri ii'hS. CPI 1Vt Range ( S. `4'
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r I r �i t, F } 1 3 i t ,1r , ;t ,yi 1 r � s ,t Barbecue
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Business name: "/ i?S ,h /. / #7G clothes Otthehe r : dryer (gas)
Address. / / A l,; rt , t 6 , r, t ' i• i ,1 r
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City /State/ZIP: rL'C' ;7 , r6 6 � Subtotal
Phone. {3) 6 .- / /J9 Fax;�-a3 )?J3? Minimum permit fee ($72.50) �2
Plan review (25% of permit fee)
CCB lic.: 8 78S.2.- State surcharge (8% of permit fee) i _.....-
TOTAL PERMIT FEE r70
Authorized signature: This permit appiimtion expires if a permit u not owned within 1s0
days after it has been accepted u complete.
Print name: I/ - Date: ; ,,_.c• ' Fee methodology sot by Tri County Building Industry Service Board
i:Motld+ -Per , Aop.doc I2/O3 440- 4617T(11/02/COM/wEa)
City of Tigard, Oregon ® 13125 SW Hall Blvd. • Tigard, OR 97223 p o } ° f �
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August 1, 2007 •: :4)-0-gratigp a
Rayborn's Plumbing, Inc.
19990 SW Cipole Rd.
Tualatin, OR 97062
Ann: Lee
Re: Permit No. MEC2007 -00444
Dear Lee:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 14155 SW 114 Ave.
Project Name: Carlson
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $62.64.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as job was canceled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Permit Specialist
Enc.
I:\ Building\ Refunds \Administ ration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 o Fax: 503.684.7297 o www.tigard - or.gov ® TTY Relay: 503.684.2772
•
Building 1) ivision R E ' X
Request for Permit Action or Refund ; nnn7
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City of Tigard CITY O1= I i G,A Ens u
BUILDING DIVISION
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960
FROM: 1 1 Owner I I Applicant Contractor ( 1 City Staff
(check one)
Name: ` . 1
(Business or Individual) ( —1
� i/! %. r / " a r'� a l � c
`'�, ;� ►. • Mailing Address: /5' , 5'c e C r �
//o City /State /Zip: , /e'S l5 f0‘. CJ,f' 9)o ‘
PhoneNo.: S'p3 - C z— 6 (11,
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
4� KO CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: Aesc 26 - ( `'j'V
Site Address or Parcel #: / 4 /1 CS ,� // � f '
Project Name: (6.
Subdivision Name: 11-4c ✓ 1( �; 1 , � ;�� i Lot #: GUS
EXPLANATION: (4' /s (6..-10e/1 1 � frvTic L
Signature: Date: 7'-Z fr -c=
Print Name: �� ic ce
Refund Policy
I . The Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
h) not more than 80 percent of the permit fee for issued permits prior to any inspection requests .
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will he returned to the original Payer in the same method in which payment was received.
�em�rt 'Ll�til y ''*'tK � v yf +� fl . •�.y�u� se�'� ' f � trr~4� pyt.wx.R � >+� a� -nom r � r:r�
l � ? i,'� tw � . ;" 1 ' :'u �'� R ROR:t50 E;USE � t tnIMEM '"�A `` ,'''
i &�1 �• ii... . 'NI:i ilfT' 'Sd�i'. � Ea'.9. ,. _lf�' t � A'�.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date ?A e 7 Bye*
Refund Processed: Date 17/ 0 7 By - jr Invoice Processed: Date By
Permit Canceled: Date , r 07 By ,gral •arcel Tag Added: Date By
Receipt #62 — ► Date „,za a, Method C.C.— Amount $
1: \ 13uilding\ Forms \ Rey Perm itAction- BIdg.Inc Rev 10 /1 /0i
11 --A0-- 1` CITY OF TIGARD 8/1/2007 �� 4:02:51 PM , _ 13125 SW H all Blvd. •
Tigard, OR 97223 503.639.4171
T IGARD.
Refund Receipt #: 27200700000000003556 ":= - . }
Date: 08/01/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
MEC2007 -00444 Reversal - [MECH] Permit Fee 245- 0000 - 431010 (58.00)
MEC2007 -00444 Reversal - [TAX] 8% State Surc 100- 0000 - 207020 (4.64)
Line Item Total: ($62.64)
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal RAYBORN'S PLUMBING, INC. 074385 Fax (62.64)
Refund Total: ($62.64)
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cReceipt.rpt Page 1 of 1
Ntio CITY OF TIGARD
7/26/2007
13125 SW Hall Blvd.
Ti ard, OR 97223 503.639.4171 2:26: 2
3PM
MI GA' RD`z
Receipt #: 27200700000000003367 OE/6, A - .
Date: 07/20/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
MEC2007 -00444 [MECH] Permit Fee 245- 0000 - 431010 72.50
MEC2007 -00444 [TAX] 8% State Surcharge 100 - 0000 - 207020 5.80
Line Item Total: $78.30
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
CreditCard RAYBORN'S PLUMBING BB 074385 Fax 78.30
Payment Total: $78.30
cReceipt.rpt Page 1 of 1
City of Tigard
N� }
Tidemark Refund Request
aTI;GARD
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit A ction or Refund form (if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Raybom's Plumbing, Inc. DATE: August 1, 2007
19990 SW Cipole Rd.
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
Attn: Lee
TRANSACTION INFORMATION:
Receipt # : 2007 -3367 Case ## : MEC2007 -00444
Date: 7/20/07 Address /Parcel: 14155 SW 114th Ave.
Pay Method: CreditCard Project Name: Carlson
EXPLANATION: Per applicant's request as job was canceled. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
[MECH] Permit Fee 245- 0000 - 431010 $58.00
[TAX] 8% State Surcharge 100- 0000 - 207020 4.64
TOTAL REFUND: $62.64
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager 411"
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
� r Case Refund Processed: Date: e/7 /C. - 7 By =- f
I:\ Building \Refunds \RefundRequest.doc 05/23/07