Permit CITY OF ' TIGARD MECHANICAL PERMIT
i� DEVELOPMENT SERVICES PERMIT #: MEC2005 -00746
�� -- 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 11/8/2005
PARCEL: 25111 BD -00309
SITE ADDRESS: 09945 SW PEMBROOK ST ZONING: R -3.5
SUBDIVISION: PEMBROOK HEIGHTS LOT: 009 JURISDICTION: TIG
Project Description: Furnace oil to gas.
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: WOODSTOVES:
GAS PRESSURE: 50 + HP: CLO DRYERS:
FURN < 100K BTU: 1 AIR HANDLING UNITS OTHER UNITS:
FURN > =100K BTU: <= 10000 cfm: GAS OUTLETS: 1
> 10000 cfm:
Owner: FEES
BILL & PAM RACZKOWSKI Description Date Amount
9945 SW PEMBROOK ST [MECH] Permit Fee 11/8/200E $72.50
TIGARD, OR 97224 [TAX] 8% State Surchar€ 11/8/200E. $5.80
Phone: 503 860 - 3839 Total $78.30
Contractor:
PORTLAND HEATING INC. •
PO BOX #9 REQUIRED ITEMS AND REPORTS
MARYLHURST, OR 97036
Phone: 503 697 - 5047
Reg #: LIC 62886 •
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 By:
$Z,„(
Permittee Signature: d 2plie "By Z_
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.
T
IN M echanical Permit Application FOR OFFICE l S1: o.l.l
City of Tigard R Y � I I. D� I �� Pmt Na 6
13125 SW Hall Blvd., Tigard, OR 97221 Ems+ `I v L " � r ��7
Phone: 503.639.4171 Fax: 503.598.1960 Pl an Rev Other Permit
Inspection Line: 503.639.4175 l `� �' � Dare/By:
*1 ` I r - .
Internet www.ei.tigard.or.us E N O V ( = : � ' �' I .. Date Ready/By I
L Su ® ptera Page enfat 2 for
Info
NotifredRrlethod: /J Info rmation
..
TIC �l '
TYPE � L D I kliC • - ION COMMERCIAL FEE• SCHEDULE — USE CHECKLIST
❑ New cansauctionAdditi6fiTalteration /replticement Mechanical permit fees° arc based on the value of the work
performed. Indicate the value (rounded to the nearest dollar) of all
❑ Demolition ❑ Other:
mechanical materials, equipment, labor, overhead, and profit
CATEGORY OF CONSTRUCTION Value: $
1 - and 2-family dwelling ID CommtciaUndustrial RESIDENTIAL EQUIPMENT/ SYSTEMS FEES*
❑ Accessory building
❑ Multi - family ❑ Master builder ❑ Other. For special Information use checklist_
Description I Qty. 1 Ea. I Total
JOB SITE INFORMATION AND LOCATION Heating/cooling
Job site address: n Air conditioning or heat pump
I. c { — 5 w t n1 8f or) L( (requires site plan showing placement) 14.00
City/State/ZIP: Ti. ✓
o ' J o a •7 2.A. '( -..d S/ Furnace 100,000 BTU (dads/vents) ( 14.00
Suite/bldgJapt. no.: / I Project name: Furnace 1 00,000+ BTU (duets/vents) 17.90
Gas heat pump 14.00
Cross street/directions to job site: Duct work 14.00
C?.r� rl1 �� . Hydronic hot water system 14.00
( 4,6(-- ( 1. �trt, - r Residential boiler (radiator or
hydronic) 14.00
Unit heaters (fuel -type, not electric),
in -wall, in-duct, suspended, etc. 10.00
Subdivision: Flue/vent for any of above 10.00
Lot
Other: 10.00
Tax map/parcel no.: Other fuel appliances
DESCRIPTION OF WORK Water heater 10.00
Gas fireplace 10.00
6 t L To 1.A S P.-1.'410A C e_ Flue vent for water heater or gas
8 ry Al n.1 35 A v cG d I t) 0 fireplace 10.00
Log lighter (gas) 10.00
Wood/pellet stove I0.0o
Wood fireplace/insert 10.00
❑ PROPERTY OWNER I ❑ TENANT' Chimney/liner /flue/vent 10.00
n Other. 10.00
Name: I3 � L L 4 /'/4 rh R I y c 2 LCU suS 1. t Environmental exhaust and ventilation
Address: 57 Range hood/other kitchen '
I 5 y . 5.14., Pe,..,, 6 r o c LC , equipment 10.00
City /State/ZIP: T 1 - c A r 0 rL 97 2 - 2 - 1 Clothes dryer exhaust 10.00
P110°e <S�7 fi — 34 3 1 Fax: ( ) Single -duct exhaust (bathrooms,
toilet compartments, utility rooms) 6.80
$( APPLICANT ❑ CONTACT PERSON Att;c/crawlspace fans 10.00
Business name: 10.00
p 01%1 1 4q,rirto i4 a t1 A.(, h L Fuel piping
Contact name: p A h L C r Ss 0 1 ✓ 0 $5.40 for first four $1.00 for each additional
Address: P. v . 6 0 K # Furnace, etc.
Gas heat pump
City/State/ZIP: M owl y c. 4 r $ 7 c. f e G d ti
97 6 3 L Wall/suspended/unit heater
Phone: (07. ) 6,f 7 - Sa y 7 Fax:: (rg#3) 6 d 7 .. p 6 7 1_ Water heater
E -mail: f. , - xd H£a171-A- @ vvt$'N Range e
CONTRACTOR Barbecue
Business name: Q d r - r `mom � r /_ ,. 11 t g J � Clothes dryer (gas)
Address: r 1 Other
MECHANICAL PERMIT FEES*
City/State2ip: Subtotal
Phone: ( ) I Fax: ( ) Minimum permit fee ($72.50) it . TO
Plan review (25% of permit fee)
CCB lic.: , 2 c C) 41 /4 7 State surcharge (8% of permit fee)
TOTAL PERMIT FEE , 'l�• Q�
110t lied signature �� This permit applica expires If a permit is not obtained within 180
Authorized
after it has been accepted as complete.
Print name: 7 ` d ., L c e SS4 ✓ o Date: d_ 7 _ 3 — ' Fee methodology set by Tri -Comfy Building Industry Service Board
k1Buid'aatPerm &tdEGPermitApp.doe 17/03
44064617T (1 raaCOlvvwEB)
• 6'd 9L90 L69 £09 oJesse° ined'f dLg :CO 90 LO AoN
I
CITY OF TIGARD .
BUILDING DIVISION . . " PERMIT #: MEC2005 -00746
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 11/8/200b
Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175 ...OW .. ..
INSPECTION WORKSHEET FOR DATE: 11/14/2005 TIME: 7:12AM PAGE: 141
SITE ADDRESS: 09945 SW PEMBROOK ST CLASS OF WORK:
SUBDIVISION: PEMBROOK HEIGHTS LOT #: 009 TYPE OF USE:
PROJECT NAME: RACZKOWSKI
DESCRIPTION: Furnace oil to gas.
OWNER: RACZKOWSKI. BILL & PAM PHONE #: 5031360 -3839
C TRACTOR: PORTLAND HEATING INC. PHONE #: 503 - 697 -5047
Inspection Request Scheduled For: Date: 11/14/2005 Pour Time:
Code # Inspection Description Confirm # Contact # Message
610N Gas line 021059-01 503.697 -5047 N
Corrections/Comments/Instructions: f1/_ Comments /Instructions:
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PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: �� � � 7 7 Date: // `� i Phone #: (503) 718 -