Permit cam `( - 1 i
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City of Tigard
Building Division \
Request for Permit Action or Refun'tf T��,. , ,T,f ;e-„,,
TO: CITY OF TIGARD
Permit System Administrator •
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960
FROM: Owner Applicant Contractor City Staff
(check one)
Name: S L �
(Business or Individual) /1 4V 1.,Atctify r/
V 0. 1 p Mailing Address: / / ?X' D9
r ,V6, 7 City /State /Zip: Ci►./4J2 t Oe■ 9 6IOc%
Phone No.: 3 ‘09;1
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES. ✓
REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: • R2 C ZO01 f7 O/ 9Z
Site Address or Parcel #: / ' o'el ,L au /Z'9 hi .
Project Name: re-f Qi&
Subdivision Name: /h7/5h / Lot #: OZ /
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EXPLANATION: L'u. Mmer eQ'7eeZed GAO / -C
�/ Date: �a/
Signature:
.411111
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Print Name: C 3,/,?- /iI9a€C
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80°.'o of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) 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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
• Rte-to S 's Admin: , Date WO (B Rte to Bld: Admin: Date p - B
Refund Processed: Date , 0 2 ZF' ; ✓F Invoice Processed: Date B
Permit Cariceled: • Date 'Aro 7 By % 7 Parcel Tag Added: Date By
Receipt #, f //g Date "eh Method Amount $ •
. I: \Biiilding \Forms\ RegPemvtAction.d e Rfv 05 ._406 02 5 6 ' z sr, c
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11 V
CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT PERMIT #: MEC2007 -00142
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 3/14/2007
PARCEL: 2S 104CA -02100
SITE ADDRESS: 13687 SW LAUREN LN ZONING: R -7
SUBDIVISION: HILLSHIRE LOT: 021 JURISDICTION: TIG
PROJECT: PRESJAK
Project Description: Gas line to barbeque.
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:
FIRE DAMPERS ?: 30 - 50 HP: REPAIR UNITS:
GAS PRESSURE: 50 + HP: WOODSTOVES:
FURN < 100K BTU: AIR HANDLING UNITS CLO DRYERS:
FURN > =100K BTU: <= 10000 cfm: OTHER UNITS:
> 10000 cfm:
GAS OUTLETS: 1
Owner: FEES
PRESJAK, MATTHEW G + CATHI Description Date Amount
13687 LAUREN LN
TIGARD, OR 97223 [MECH] Permit Fee 3/14/2007 $72.50
[TAX] 8% State Surcha 3/14/2007 $5.80
Total $78.30
Phone: 503 -524 -4146
Contractor:
SHAMBURG HEATING LLC
PO BOX 829
TUALATIN, OR 97062 REQUIRED ITEMS AND REPORTS
Contact #: PRI 503- 692 -5563
FAX 503- 691 -6855
Reg #: LIC 126881
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: , j � � � 1_ �� < Permittee Signature: 07
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.
M L 07 . 08: 1 2iih 5 0 3 - 6 9 1 - 6 8 5 5 p . 1
1 4 2007
ostaBr . csi tyiy/Di a 3
13125 SW Hall Blvd., Tigull. OR illi** '
Phone: 5034539.4171 Foe: 503.59&1960 Elsa R Odes Penn*
insP"Ti°11 Une: 5(8-6:1"175 CITY OF •Ii OAR D __. ÷ .,a,:',:- . 4 i I -..:., mi . Rcedyier
z w i w 1 RI Sea rase 2 SOF
Internet www.ci.tigard.or.us
BUILDING DIVISION Nodriedadegmz _ Supplaueutsi teCernualon
0 New construction 131Cddition/alteraricaskeplacerneat Mechanical omit fees '. are based on the value 011ie work
0 Dernolition 0 Other: pi:domed. Indicate the value (rounded to the nearest dollar) of all
cacctsanical materials. equivazent. labor. overhead, and profit
• '' • . ' :... : ' •: - ' ' . '' ..... • : 7: ' - :- .. 0 4EccoMciF:c0406MicTitiN ' . , .' - • : ....:.; -: Valu= S
a'rertd 2-family dwelling 1:1 Commercialfindustriel 0 Accessory building ?: .....
0 Multi-family 0 Master builder 0 Other: For specks' I ittformatioa are checklist
Description 1 Qty. 1 r.a. Total
'"f '"" . .-:"' "-..-..:".:,::,-** SITE" liqlZE0RNM AND itaciinok ' - .1:' :. - . ' .: ' Reatzerenazine _
Job site eddres57 / 4,2 414.e.4r7 _Z./ 7 . Air conditioning or bent pomp
Omar= tim pun sia.rincalanwren0 14.00
City/State/ZIP: - 7 , ryi,--0/ 02 9 9,2.13 Furnace 100,000 EfUiduenivenral 14.00
/
Suite/bldg./apt no.: 1 Pzujoa name Verneee 100,000+ BTU (doesesems) , 17.90
Gas hear Dump 14.00
CroSs street/directions to job site
Duct work , 14.00
Hydranie bummer system 14.00
Residential boiler (radium or
hydnadc) 14.00
Unit beams (fuel-type, not electric),
in-Wall. in-duct, suspended. etc. 10.00
Subdivision: 1 Lot no.: Ftarivent for any of above 10.00
Other
Tax 10.00 1
reap/pareel no.:
Other furl appliances
,...
• . ..: . . _L . ; :::_ . ...,nEtquftioN oi?? :: : . . . ; : L 1 .. 7 ! .. ' ." " ..'......, Wairr hCulcr 1000
6t.5 sic A.6q Gas fireplace , 10.00 ,
Flue vent for meter beater or gas
frrepbee
_ 10.00
Lon lig= (gat) 10.00
wend/pellet stovc
Wood ftreplacermsen 10.00
- 1:;. , - - '
Chimneydixterifieudvent 10.00 •
..'11 ••,i . .::' ...-: .
10.00
Name: Jet rar Environmental exlmost mad ventilation
Rxtge bood/ether kitchen
Address: 4 9 c. ei .(„4 . .bauTnan 10.00 •
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..------ .../ z. ..,, ...
City/State/ZIP: /y4 / (1/C-- 7 .,13 Clothes *yet exhaust 10.00
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Singh-duct exhaust (hannooms,
Phone: ( ) s y/ V69 Fax: ( ) mires coragartments. utility mums) 610
. . : . . " ."" s " -- ' " ' ". PERSON ' • - - .- ". . AnkierawlSpace form 10.00 _ •
_
. • . ..- -• 0,,41 .
" - - - - " • :: .." f. • -
10.00
Other:
Business name: Feast *OM
Contact name: S5.40 for first four; 51.00 for rash additional
Furnace. etc. -__ _
_
Address:
Gas hest Putt*
Wall/sespend.ed/tarit heater -
City/State/Z1P: '
Water hears
Phone;( ) [ Fax: : ( )
Fireplace
Ita7e .
E-roall: (
/ .5; 5: 10 ,_, •
' .. - itiriUCTOR f :. i'- -.-":' :-: • ::.- ' • -,. .. • ' • :-.. 7 Barbecue
• . ' -: ." ..• -: - : ....]::- --: :: - •
and= diver (gas) , _.
Business name: ‘.. 94 409/ AI 4/earGrij 1...46..- Other. •
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-, - . -- - iiiiritketAnTVElg,s'• •::•.• .:....: • .. • .
Address: /0 e g
subtota 1 5.910 .
4) ,
04 q 7,06'io'-- Watirmun permit fee (S72.50) i 9?. 5
CStstea1P: --7
man review (15% of Penult fec
Phone: ) z -Z3 5 I F32-1 ( 60 kw-471
.
Siam 80=1181gc 03% Of 000 *0 54 21 0
CCB liC.: e : ,.. fp
TOTAL Pr/MIT FEZ 12: 3/1
r; -- - permit appikatiss es;they Its pernat is am stus within 180
days ate, it lbws bats accepted ms 0 241 1 4
Authorized silPureal
1 Dam 40 4 I " Fee Maihed°194Y igral.41.44°".47 illadi°8 ladwcrY Saks rac'cird
I Print name: 5'&11 • 3
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