Permit •
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1
m . Request Permit Action
q
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
• Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
" Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: /VEC ae /02 — 00 yv /
Site Address or Parcel #: / . 02 3 5' S- t) L.7;' S j
Project Name:
Subdivision Name: Lot #:
EXPLANATION: c'4 r& L A A / S T o 2 0 2 — P - , 5 6
Signature: Date: e / //y
Print Name:
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date B _ Rte to Bld: Admin: Date ...AMEN _4;17 B _4
Refund Processed: Date By 4 °''' Invoice Processed: Date By
Permit Canceled: Date e FAA Z By ' • ' arcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012
07/30/2012 MON 13:48 FAX 5032865194 FIRST CALL HEATIN 0002/012
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V - 0 ---------
Mechanical Permit ApplicatiRECEIVED '(1' 4 ()I • 1 II i. 1 •I t) \ I 1
City of Tigard Received
Drew i 3 2 , sr Permit �I-O0(
N .,... 13125 SW Hall Blvd., Tigard, OR 97223 JUL q 0 ?012
Plan Review • ' I Phone: 503.718.2439 Fax 503.598.1960 e, _ Date43T. Other Permit:
1 ir.%Ro Inspeedon Line: 503.639.4175
r
Internet www.tigard-orgov CITY OFTIGARD NItei=: hisi / lil See Page 2 ter
w Supplemental information
BUILDING DIVISION •
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- . Mechanical peanut hes* are based on the value of the work
0 New construction I Addition/alteration/replacement pertbrined. Indicate the value (rounded to the nearest dollar) of all
0 Demolition 0 Other: mechanical materials, equipment, labor, overhead, and profit
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l - Eutd 2-family dwelling 0 Commercial/industrial 0 Aocessory building Fos spedal bOnnation ase dieddisi.
0 Multi-family 0 Master builder 0 Other: Description I Qty. 1 Ea. I Total
Rea '''''rAT'Lt?,' '1•Weln HeafinakoolIng:
lob site address: / 2 z36 ,s-i-i 77),ThiS St- (regains tate plan showing placement) 46.75
Furnace 100,000 BTU (ducts/vents) 46,75
City/State/ZIP: 7 -, ea „,„, ox q ?-z Z. 3 Furnace 100,000+ BTU (duets/vents) 54.91
Suite/bldg./apt. noV I Project name: 2, (poq .. T pump
(requires site ohm 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-typo, not electric),
in-wall, in-duct, suspended, etc. 46.75
Subdivision: I I. no.: Flue/vent for any of above 23.32
Other: 23.32
Tax map/parcel no.: Other fuel appliances:
itiwo water heater 2332
Gas fireplace/insert 33.39
nsiati gm Above ii/61-4d li e 41--;,:ty Flue vent for water heater or gas
fireplace 23.32 _
vi• I i71/4/c- Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/Insert . 23.32
tIPWATEPTirrftlrWVIVIVIINIFMtitr.lrlqwacij,21:.',4 Chhnney/liner/flue/vent 2332 _
. . a s i . . , - - ' s " . . . , . : , s 1 , 9 : 1 ; , - s . . . : 4 „ . . - 4 4 . • . . . - A - 4 i t . ' '4.421,-4.t. , 47.11 - t r t - , , , , , . - r w , s other a d ta L t 2132 2 - 3. 3z
Name: c a , 1 - A 1 eeri T Environmental exhaust and ventilation:
Address: /223 C .544 7 . S.f-- , Range hood/other kitchen
Minnie= 3339
City/State/7_1N7 , q oR 9 ? 2 2 3 Clothes dryer exhaust 33.39 _
Single-duct =lutist (bathrooms, •
Phone: (513 ) Lj - .', • '9' 2- Fax: ( ) toilet oompartments, utility rooms) 23.32
igk Am. .4sERF .. ',r-TnnvIriqnVia74:7r7,TAMTZTViTql,Vreir51521kTiricir17,A Auk/ n
itiahh: e '.. I' . '.:-'_ ''n'AIA.IP- .”' .4t '&...gii.4*- It'AP*4 ,t.P - craw I - ace thns 2332 -
A ,..._ ,_
Business name: Other: 23.32 6t 047,1 ble“-T-os Fnel IOW:
Contact name: )9 FiLA e. S1415 for first four; $4.03 for each additional
Address' / coo 5•D A 141.iadil Furnace, etc.
Gas heat pump
City/State/Z1P: /95)9fad Og 7 Wall/suspended/unit heater
Phone: ( 93) 23/ - 32// I Fax: : ( ) 2-81a- 6711- Water heater
Fireplace
E-mail: /71 tr,4,4 /. , Al IK ..f 1 1 - C i Raw
wegravforav ql-Fin-tw,-,7,-„Tagrgx,r4.
L._.(s. tr,- - ..ti , ii •:.' ,Ii,....4.?„-Elist-ai:wspA,...,InzarMIV-21.1111,,... Barbecue
Business name: fi6t (Oki #1711-m , Clothes dryer (gas)
Other:
Address: , ive Lw.7e...' 'Nrotrev,mr.zrommr
..., .rii ...Y5,..a.N,t,ene 'it, - 1.`o.r..“.4,...:2AN.o..i...,,,.
City/State/ZIP: fg\itiamd O/e q 7-zi / Subtotal 23. 3 1
Minimum permh fee 090.00) g
P 'one: (93 ) 231-231/ I Fax: (9)3) 257.- V'? i Plan review (25% of permit fee)
CCB lic.: /02 03 State surcharge (12% of permit fee) Q. 8
TOTAL PERMIT FEE I 06 .ist)
Authorized signature: signature. permit application expires if a permit is not obtained within 180
days after k bas been accepted as complete.
I Print name: if :‘ , — g _ Date: )0 2,_ • Fee methodology set by Tri-County Building Inchtstry Service Board
I
! 1-1BuildIns1PermhsIMEOf - .. • 1 • • .d0C 03/07/1 • 4404617T (11/02/COM/WES)
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07/30/2012 MON 13:47 FAX 5032865194 FIRST CALL HEATING 0001/012
1650 NE Lombard Street
Portland, OR 97211
503/231-3311 FAX:503/286-5194
360/693-3311 Vancouver
Heating & Cooling www.FirstCallHeat.com
FAX Coversheet // additional pages to follow
Date:
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To: C i h . rijaPX-
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