Permit CITY OF TIGARD MECHANICAL PERMIT
11 4 s COMMUNITY DEVELOPMEN Permit #: MEC2012 -00147
T [GA R D 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/20/2012
Parcel: 1S134CB10201
Jurisdiction: Tigard
Site address: 12476 SW EDGEWATER CT
Project: DONIVAN Subdivision: MILL VIEW Lot: 2
Project Description: Extending gas line for new gas stove.
Contractor: OWNER Owner: DONIVAN, ETTA A
12476 SW EDGEWATER CT
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Specifics: Description Date Amount
Fuel Piping 03/20/2012 $14.15
Type of Use: SF 12% State Surcharge - Mechanical 03/20/2012 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 03/20/2012 $75.85
Occupancy Grp:
Stories:
Fuel
Fuel Types: Natural Gas
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 - .
Issued By: Permittee Signature: 777 ciEff
wit _
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.
Mechanical Permit Applica Zt:T roll orrlci.: usl: oNI.V
City of Tigard Date/B Received
) )V i1
`•f ��
q 13125 SW Hall Blvd., Tigart, .•• ' 223
• 1 C Phone: 503.718.2439 F: , F. it .598. , Plan Revi
Date/By: Other Permit:
't I G A li p I nspection Line: 503. • ?: a , 1� �� Date Ready/By: la See Page 2 for
Internet: www.tigard - or. e t V \ - ,Z e(s' Notified/Method: Supplemental Information ''\. BM
` C .� COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
� Mechanical permit fees' are based on the value of the work
❑ New construction ddition/aation/replacement performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit
Value: $
CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES*
- and 2- family dwelling ❑ 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:
Air conditioning
Job site address: / Z 4 71a c r c-u at . (requires site plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46.75
City /State /ZIP:
(1 3/t w� Or e. * C77 i Furnace 100,000+ BTU ( ducts/vents) 54.91
Suite/bldg./apt. no.: Project name: b 11 / v u 0 Heat pump
(requires site plan showing placement) 61.06
Cross street/directions to job site: Duct work 23.32
Hydronic hot water system 23.32
Residential boiler (radiator or
hydronic) 23.32
Unit heaters (fuel -type, not electric),
. in -wall, in -duct, suspended, etc. 46.75
Subdivision: Lot no.: Flue /vent for any of above 23.32
Other: 23.32
Tax map /parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
Gas fireplace/insert 33.39
Pmt t C C, (c 5 r 4 A' e- / " i g 5 3 llt Flue vent for water heater or gas
!f fireplace , 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
❑ PROPERTY OWNER I ❑ TENANT Chimney/liner /flue /vent 23.32
Other: 23.32
Name: 1 - K t ✓/i v1 Environmental exhaust and ventilation:
Address: / 2 y 7 / 6' d C.---+ Range hood/other kitchen
�(G co G.4 � equipment 33.39
City/State /ZIP: 4, ( / 0v- . e/ 7 2 2 3 Clothes dryer exhaust 33.39
r / j3) p Fax: Single -duct exhaust (bathrooms,
Phone: (5 3 2 ( ) toilet compartments, utility rooms) 23.32
❑ APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 23.32
Other: 23.32
Business name: pip g
ill P � ! or .40.1).e_ Fuel pi pin
Contact name: $14.15 for first four; $4.03 for each additional
Address: Furnace, etc.
Gas heat pump
City/State /ZIP: Wall /suspended/unit heater
Phone: ( ) Fax: : ( ) Water heater
Fireplace
E-mail: -
Range I /it IS
CONTRACTOR Barbecue
Clothes dryer (gas)
Business name: tea_ /.. .
(/"" Other:
Address: MECHANICAL PERMIT FEES*
City /State /ZIP: Subtotal / it , 15
Phone: ( ) I Fax: ( ) Minimum permit fee ($90.00) q0 _du
Plan review (25% of permit fee)
CCB Iic.: State surcharge (12% of permit fee) /p
TOTAL PERMIT FEE /a), CD
Authorized signature: This permit application expires if a permit is not obta ed within t80
days after it has been accepted as complete.
Print name: 11 I 4,4 ,,,,( —00v11 ✓ 4 H Date: 3 - ZO -j 2- • Fee methodology set by Tri -County Building Industry Service Board
I:\ Building \PermitAMEC- PermitApp.doc 03 /07/12 440- 4617T(I /02/COM/WEB)
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.
I:\Building\Permit \MEC- PermitApp.doc 03/07/12 2
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing per mits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
I own, reside in, or will reside in the completed structure and my general contractor is:
Name CCB# Expiration Date
I will inform my contractor that a II subcontractors who work on the structure must be
licensed ' the Construction Contractors Board.
I will be performing work on property I own, a residence that I reside in, or a residence that I w ill
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
/1 13 --- 6 kt V it V
Print Name of Permit Applicant
'DT 4111111■ — 3 -7,c) 1Z
Signature of Pe it Applicant Date
Permit #: (flS.0 3.01� -ong Li 7 7
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Address: I ( �7(0 %i.l.)r Ct . . ` .r�
Issued by: 13 . % Date: _3 0 42, x-11'
This Copy for Permit Offices