Permit - DQ -eacio3 -600 l 40
- Mechanical Permit Application FOR OFFICE USE ONLY
City of Tigard DateBy Cl> b O. Permit No.: �! {\ ( £CoCn -G0 j C�
13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
• Phone: 503.639.4171 Fax: 503.598.1960 / y.,�,, � f� Date/By: 0 / �' Other Permit:
Inspection Line 50' 39. j�re Date Ready /By: funs 0 See Page 2 for
Internet: www- I rd.o s Rn Notifed/Method: / Supplemental Information
No A1-‘971/ s _ �-// 1� , - ..10/2-,9 ,7o
TYPE OF.WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
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.
CATEGORY OF CONSTRUCTION Value: $ /22 400
RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
❑ 1- and 2- family dwelling I 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
f ^� Air conditioning or heat pump
Job site address: -
/ _3j- / 3) '(3EyELg 9.4 • (requires site plan showing placement) 14.00
City/State /ZIP: - )i¢.D 0 la. 9-7 Z2,3 - 6leD9 Fumace 100,000 BTU (ducts /vents) 14.00
r _� Furnace 100,000+ BTU (ducts /vents) 17.90
Suite/bldg. /apt. no.: Project name ' K O r - / Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00
Hydronic hot water system 14.00
Z 'r 13&JEL- A-f•- . Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 10.00
Flue /vent for any of above 10.00
Subdivision: Lot no.:
Other: 10.00
Tax map /parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
r_'.1 Gas fireplace 10.00
i*41 T..l - D -i LE ., a l.1,6 Flue vent for water heater or gas
fireplace 10.00
Log lighter (gas) 10.00
Wood /pellet stove 10.00
Wood fireplace /insert 10.00
Chimney /liner /flue/vent 10.00
❑ PROPERTY OWNER ❑ TENANT Other: 10.00
Name: 7 p ,,, c Loc0 . e _ Environmental exhaust and ventilation
Range hood /other kitchen
Address: IZg -t s„.. Dec.F1 A H equipment 10.00
City/State /ZIP: (SG_ � ���. Da. 97 D 3.5 Clothes dryer exhaust 10.00
l Single -duct exhaust (bathrooms,
Phone: (5p3) Fax: Sc.)) 2, 13 - / 53 ` toilet compartments, utility rooms) 6.80
❑ APPLICANT (2 CONTACT PERSON Attic /crawlspace fans 10.00
Other: 10.00
Business name: D 1 v6.e51 G 16.3, [Dt- AsT2?CT7 0.3 Co OG OR. _ Fuel i in
PP t;
Contact name: Tovti Cd -gke_ $5.40 for first four; 51.00 for each additional
Furnace, etc.
Address: 12'i4 d3 5..> 012e -r/Aar> 41t..._ Zed
Gas heat pump
City/State /ZIP: 1_0, ice_ d is a2 91 Zt 9 Wall /suspended /unit heater
/
Phone: (5) 293,_ / 11.4. Fax:: (�5 2/5 `
) r)3 - water heater
,3
Fireplace
E -mail: "DI V QS 1 G D tv 1 t)t - rm. O tivrolni 1-- - L 8 v1'1 Range
CONTRACTOR Barbecue
Clothes dryer (gas)
Business name:
Other:
Address: MECHANICAL PERMIT FEES*
City/State/ZIP: Subtotal
Minimum permit fee ($72.50)
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB lic.: State surcharge (8% of permit fee)
TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
----. .A.t..0-0 Authorized signature: V d ays a i t has been accepted as complete.
Print name: - DpuQ41,N ' , 144 oK.IN Date: 1- /2 / pi_ * Fee methodology set by Tri- County Building Industry Service Board
B \ \ M
i:\ uilding Permits EC- PermitApp.doc 12/03 440 -4617T (1I /02/ / COM/WEB)
Mechanical Permit Application - City of Tigard
, Page 2 Supplemental Information
Commercial Fee Schedule:
Total :Valuation r < Perri n Fee; +._ :
$1.00 to $2,000.00 Minimum fee $72.50
$2,001.00 to $5,000.00 $72.50 for the first $2,000.00 and $2.30
for each additional $100.00 or fraction
thereof, to and including $5,000.00.
$5,001.00 td $10,000.00 $141.50 for the first $5,000.00 and
$1.80 for each additional $100.00 or
fraction thereof, to and including
$10,000.00.
$10,001.00 to $50,000.00 $231.50 for the first $10;000.00 and
$1.35 for each additional $100.00 or
fraction thereof, to and including
$50,000.00. .
$50,001.00 to $100,000.00 $771.50 for the first $50,000.00 and
$1.25 for each additional $100.00 or •
fraction thereof, to and including
$100,000.00.
$100,000.01 and up $1,396.50 for the first $100,000.00 and
$1.10 for each additional $100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans.
i:\Building\Permits\MEC- PermitApp.doc 12/03 2