Permit MI! CITY OF OF TIGARD • MECHANICAL PERMIT
COMMUNITY DEVELOPMENT PERMIT #: MEC2008 -00127
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 3/12/2008
PARCEL: 2S112BC -09000
SITE ADDRESS: 14755 SW 80TH AVE ZONING: R-4.5
SUBDIVISION: RAZE MEADOWS LOT: 013 JURISDICTION: TIG
PROJECT: KLEIN
Project Description: Installing gas fireplace.
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: 1
> 10000 cfm: GAS OUTLETS:
Owner: FEES
ROY KLEIN Description Date Amount
14755 SW 80TH
TIGARD, OR 97223 [MECH] Permit Fee 3/12/200E $72.50
[TAX] 12% State Surch 3/12/200E $8.70
Phone: Total $81.20
Contractor:
FIRESIDE DISTRIBUTORS
18389 SW BOONES FERRY RD
PORTLAND, OR 97224 REQUIRED ITEMS AND REPORTS
Contact #: PRI 503 -595 -3726
FAX 503 -620 -5699
Reg #: LIC 40979
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: Permittee Signature J —� 7 4G/?cf /l/
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.
k.,.�r � CITY OF TIGARD 4/14 /200
` 1 I 13125 SW Hall Blvd. 12:36:3
-, Tigard, OR 97223 503.639.4171
TI"GAR
• Refund Receipt #: 27200800000000001220
Date: 04/14/2008
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
MEC2008 -00127 Reversal - [MECH] Permit Fee 245- 0000 - 431010 . . (58.00)
MEC2008 -00127 Reversal - [TAX] 12% State Sur 100- 0000 - 207020 (6.96)
• Line Item Total: ($64.96)
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal PAUL VANDEREEMS /FIRESIDE 612143 Fax (64.96)
DIST OF OREGON
Refund Total: ($64.96)
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Mechanical Permit Application FOR UFFICF USG ° \'I.l'
, I
r E @A E D Rweiva► - ' Permit No.: C ao ! _ —.(JUG
City of Tigard ;� 17ate/Cty: J I , s ,j
S 3125 SW Hall Blvd„ Tigard, OR 9' " Plan Review Other Permit:
I li ''
3 , Phone: 503.639.4171 Fax; 503.59:.1 • t00 Date/By
r I G , R. �, inspection Linc: 503.639.4175 MAR 1 1 Date Ready/By; riots; ® See Page 2 for
Internet; www.tigord -or,gov CITY OF TR3PRD Notified/Method: Supplemen
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;1111 > ; :.`:�'. I, 11 ,1 ;191,.1 :G. ,II l ' �! l i . �';:;.1 �..'.. 'l'iV '9 .� ;. • � �, .,
,.: I`, Il., .,,, l!p:- .,,M1II .: . '_,b pl , -0 1,, I Dills G .,,,... ..I,iill •v m m .. i , i., WI t c v alue o k .
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.;;, ... I � "� � ttl`'' ° -•I� "�' •' ' ' •' '� McchanicAl permit fcc�" are bas on the value of the work
in New construction ❑ Addition /alteration/replacement performed. indicate the value (rounded to the nearest dollar) of all
❑ Demolition n ❑ Other: y mechanical materials. equipment, labor, overhead, and profit
i. " !:I'.,• •i 'lli i'lllj� I : II i : ,N I W�t�S''Il W,��Il ' I!Il lit ill' r.�. .'1.l 11 i i i :. ": 1 ,
Value: �'
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,:.,. ...: .::....: , I ,.. ,:.,,. � :,li;1„11111 /industrial IINlI ?,,� �. + ,.:. ..I. ....1 �� �'�M�' . , .. „�,� I II I
[x I- and 2- family dwelling El Commercial/industrial 1:1 Accessory building II Ili Iilll „ "" r "' "''''' ° "` ` ' I ' ' `
For special information ILre checklist.
❑ Multi- family ❑ Master builder �� I ❑ Other: Description 1 Qty. J Ea. I Total
,::; ,.;.., ,q �1...,....•:1'.. iJOI II
'•;a;.,. I II I,, •• •- :, "' '';' �I I i :.;� Hesttln cootirg
,.. ..:.:.; ..,:,. , ' ' iy��l ' >§�j�.��.,'��I� .. Illillll: �Il!'���illll i i.iV, �
d:!: ...,... ;::�Ilf,, i I i„ Air conditioning or heat pump
Job site address: 1` 5 5 5.u) �� _ (requires site pine $bawintti placemc7 14.00
City/State/ZIP: — • r , , g a - D- Furnace 100,000 BTU (ductalvaets) 14.00
Furnace 100.000+ BTU (duets/vents) 17.90
Suite/bldg. /apt. no.: Project name: j, Gas heat pump 14,00
Cross street/directions tojob site: Ductwork 10.00
Hydronic hot water system 14.00
Residential boiler (radiator or
—
i hydronic) 14,00
Unit heaters (fuel -type, not electric),
in -wall, in -duct, stuff' ended. etc. 14.00
Flue/vent for any of above _ 6.80
Subdivision: Lot no.:
Other: 10.00
—
Tax map/parcel no.: y�{yppp Other fuel appliances
i::l' .,i:il!I!•i! vl: :'lei!'! 1i'' illlitjl:'i',yY.� ,. p r 1 1 y I' ."'yl;l: : Water hcatcr
..': - I i !:iii :i • .'41, i l i llll'lll l p l ::: C l, o P , X1 11 ■ i .d�,,. i, ll.,el ii, 1;0 ii,m: .� .. I I.. • e.,
li .,:: Gas fireplace 10.00 • I 10.00 lrl.ea
n i _ Flue vent for water heater or gas
fireplace 10.00
` Log lighter (tars) ` 10.00
Wood/pellet stove _ 10.00
Wood fireplace /insert 10,00
, ; ' lilt l 'I d: •u, I I i' ' II:' .., Chimney/1incr /flue/vcnt 10.00
..i .:'• .... , . !...... iii... r,Cy , I,I '` : �IJ!' it l it . ,,; !:': a : �. !. 7$ I; l i " Ot 1 00 • , i I,.. ,:tl; .. her: 0.
Name: �� 1 r 1 1 n Environmental ethaust and ventilation
Range hood/other kitchen
Address: I LI sr...._ 510. ea fo`_ equipment 10.00
ry /State/ZIP: !', 1 Clothes dryer exhaust 10.00
Ci
t1 arrd QR °11 3-�I - Single -duct exhaust (bathrooms,
Phone: so� 31 {a F ax: ( ) toilet compartments. utility rooms) 6.80
{lii�i:i:::i!' ,Fiji .YiI:LLE':F► „': -
'i' ;''• -. i1: :;1i. •rl•: , ll . i i III , .. ∎,_ i ,.,.. Attic/crawlapaee thus 10.00
� .. • •.. ..:�„ .: • : . � � � III I'I � � .. �.,: � 'Ilia i I
..r(; .... , .nn•• ',llliUl. , f,lIl� i o r xapi r i • `�J„
Other: 10.00
Business name: • i • I b D If", i Fuel piping —
Contact name: h INA 55.40 for first four: S1.00 for each additional
Furnace. etc.
Ad • a • ` 1 D ' _ . it. Gas heat pump
City /State/ZIP: posA - OR Ci i • Wall /suspended/unit heater
Phone: I • • i / Fax:: 1 ) %/ L i CI • Water heate .
Fireplace
E -mail: Range
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, {.. i•I'i ':ill,�l9;ri:11111 1i:i.. WLV,t��� ;i''i1 :i „,,,, '.!till! ::'ll., IJII I '' Barbecue
I : (,I„ , ...:�.•.....,, .. , .., . ; •,:!i , I::I I Clothes rye
Business name: o es d r (bat)
ifpsi'G1�0 `�1'af Dp � f0tiOn Other: { y y y� ` �y 1�7 F d
Address: , / r u�lllll II I yIII R V diir - I�Yot,T'�,-1li11 Il:liiiil I { I Ii I
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_S.la. .. i ..i. liiiik i �, ... r n. -, -... 1. ( ,,.�....
City/State/ZIP; 9ubtotnl
Minimum permit fee ($72.50) 7d e S - 0
Phone: ( ) Fax: ( ) Plan review (25% of permit fee)
CCB Iic,: U 6,7 Gj State surcharge (17.% of permit fee) if • 7U
`I+ TOTAL 'PERMIT FEE dd I .2. a
t This permit application ecpira if a permit Is not obtained wit!fm Ian
Authorized signature ii / / / f! i days slier it has been accepted as complete. `
Print Hama ■ . ' ` � f{ C k 1 Date: ` • Fcv methodology set by TN -County Building Tndservice nsrry se Bowl
r: Build',nplperm:t0'MF.r.Perm ` App.doc 01/t9/0 441)44 I n (I 1/02000M/WEB)
•
• City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
. 11
•
• IN..:
4
T I:GARD E
April 14 2008 "$ '
Fireside Dist. of Oregon
18389 SW Boones Ferry Rd.
Portland, OR 97224
Attn: Amy Butterfield
Re: Permit No. MEC2008 -00127
Dear Ms. Butterfield:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 14755 SW 80 Ave.
Project Name: Klein
Job No.: N/A
Refund: ❑ Check # in the am ount of $ .
® Credit card "return" receipt in the amount of $64.96.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as work was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
I:\ Building\ Refunds\ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772
•
• 11111
City of Tigard
T l c A R D Tidemark Refund-Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Paul Vandereems DATE: 4/14/08
Fireside Dist of Oregon
18389 SW Boones Ferry Rd. REQUESTED BY: Dianna Howse
Portland, OR 97224
Attn: Amy Butterfield
TRANSACTION INFORMATION:
Receipt #: 2008 -810 Case #: MEC2008 -00127
Date: 3/12/08 Address /Parcel: 14755 SW 80th Ave.
Pay Method: CreditCard Project Name: Klein
EXPLANATION: Per applicant's request as work was cancelled. Refund 80% of permit fees.
REFUND INFORMATION: .
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245- 0000 - 432000 $ Amount
(MECH] Permit Fee 245- 0000 - 431010 $58.00
[TAX] 12% State Surcharge 100 - 0000 - 207202 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager c i ' jy --vP
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY, • -
�/ Case Refund Processed: Date: B , -
/
1:\ Building \ Refunds \RefundRequest.doc 05/23/07
A CITY OF TIGARD 4/14/2008
1 - _ _ 3_PM
e 131zSSw1lan I .
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Tigard, OR 97223 ;03.639.4171
f CG'AR'a
Receipt #: 27200800000000000810
Date: 03/12/2008
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
MEC2008 - 00127 [MECH] Permit Fee 245- 0000 - 431010 72.50
MEC2008 -00127 [TAX] 12% State Surcharge 100- 0000 - 207020 8.70
Line Item Total: $81.20
Payments:
Method Paver User ID Acct. /Check No. Approval No. How Received Amount Paid .
CreditCard PAUL VANDEREEMS / FIRESIDE BTT 612143 In Person 81.20
DIST. OF OR
Payment Total: $81.20
c Receipt.'pl Page 1 of 1
04/08/2008 08:15 5036205699 FIRESIDE DISTRIBUTOR PAGE 01
RECEIVED
APR 8 2008
IA Building Division
° CITY OF TIGARLD
i i (_: A I`? Request for Permit Action BUILDING DIVISION
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www•tiigaxd- ot.gov
FROM ❑ Owner [Applicant 0' Contractor 0 City Staff
(& ant)
REEIJND OR Name:
INVOICE TO: Moir= ^r 7ndiTldu:) elli' `' S 1 s 1 ISk r I 4 e in
Mailing Address: 1' 3 % a - , • + OA 1 . ' A 6.
V ® I ®
City /State /zip: Pp,r k-la a R. q a
00 f 44) Phone No.: 503- • - ,
•
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
CANCEL PERMIT APPLICATION. .
L REFUND PERMIT FEES (attach receipt, if available)-
E] INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: _ me_C.aora -opt
Site Address o r . Parcel #: 1‘1163 5-1.,k) . $ Q +�, c1ax vt , D R o -- 1 ad- 3
Project Name: ( � Q v i K t U n •
Subdivision Name: Lot #:
EXPLANATION: N Ic.) p QX afk \C+t I1.2a
Signature: ,/... A R. �, �! ... .../'� Date: �- ) -O 9
•
P.riotName: ' AoY1l l ', I }
8.dea.Ealin
1. Thy t)irectnr or Building Official art, atrhnrvc the refund of
a) any Coo whkh WAS erroneously paid rrr collected.
b) not more then P.0% of the land use application fcc when an application iR withdrawn of canceled bofrne may review effort has been expended,
e) nor more ►limn Aft" /n of the land ure application Fro for iasucd pertain,
a) not more than BO% of slat bvildine plan re -iew fee c •hen +m application is canceled berme arty plan resew effort lima been emended.
d) not morn than so% of the building . *trait fee for ixs.&ad limonite pdot to any inxpaceian emote.
2. Refund* a5r1 be vosentd to die oriparat PRycr in the .ARtmc method in which paynrrnc roam received. Please allow 1 -2 weeks for processing tcf rrn*.
FOP: c,;lf:i:ICL• T_i5F. ON I_l
Rte to S c Admin: Blinn I B. Rte to Blel, Admix: Date 43 B •'4
ltefit:td Processed: Da Arrarmulprad Invoice Proccsaod: Date EliMiM
Permit Canceled: Date ' A7�a By _ &o, ii Parcc! Ta_ Added: Date By
Rece" -t # A, Date 3 /1_,RITM Method Amount . A,
1:\ Brnldina \FoernARegPerrnitnainn.d e . v O5 /24 /('(
•
CITY OF TICARD !12
III _ 13 125 SW Hall 131~4. 2:35:46P111
N Tigard, Olt 97223 503.639.4171 1.
m TIGARD-
w
(J
a Receipt #: 27200800000000000810
Date: 03/12/2008
Line Items:
Case No Tran Code Description Revenue Account No . Amount Paid
114EC2008 -00127 (117FCH] Permit Fee 245 - 0000 - 431010 72.50
AtEC2008_Q0127 [TAX] 12% Stale Surcharge 100-0000-207020 &70 .
o Line Item Total: $81.2(1
D
co
Pad orients:
ix -
•
in Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
H
m
Lit CreditCard • PAUL VANDEREEA•IS I FIRESIDE BTT 612143 jneLin Roc. 81.20
H DIST. OF OR
to
C'
tr Payment Total: 581.20
M •
LL .
CI11 Or TIBARD PERMITS
1 25 9Y 1401.1 OLUD
6P$tO, OR. 97223
110141111 I ..1 €1111714802880112065B111
IERCltI111 RC 6883180696
crl cn UI �776 t. - •
LD SALE
in RECORD 41: B14 911.11 088114
N OW: MN It 8B 19E: 12138
Lo 08111: 612141 •
m RUS RESP0RSE: 4
rn
ODDNESS OR 5 CIBIT ZIP IWTCI1 .
in TOTAL $81.20
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