Permit CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT Permit #: MEC2013 -00216
T f G A RD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/22/2013
Parcel: 2S103DA04000
Jurisdiction: Tigard
Site address: 10860 SW PARK ST
Project: Epeneter Subdivision: DERRY -DELL NO.2 Lot: 37
Project Description: (1) gas stove installation and gas line
Contractor: OWNER Owner: EPENETER, FREDERICK J & BEVERLY
10860 SW PARK ST
TIGARD, OR 97223
PHONE: PHONE: 503 - 639 -6468
FAX:
FEES
Specifics: Description Date Amount
Fuel Piping 04/22/2013 $14.15
Type of Use: SF 12% State Surcharge - Mechanical 04/22/2013 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment - Mechanical 04/22/2013 $75.85
Occupancy Grp:
Stories:
Fuel
Fuel Types:
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 1.800.332.2344.
Issued By: `/ d L l L /, l Permittee Signature: /
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 ApplicatI CE FOR OFFICE USE ONLY
2 / r -
City of Tigard Received
Date/By:
414 ' 3 c( Permit No c40(3. 00-I ?°
13125 SW Hall Blvd., Tigard, OR 9722A PR 2 2 2013 Plan Review
I 11 Phone: 503.718.2439 Fax: 503.598.1960 DateBy: Other Permit:
T t G A R D Inspection Line: 503.639 CITY OF TIGAR Date Ready/By: kris: la See Page 2 for
Internet: www.tigard- or.gov BUILDING DIVISION Notified/Method: , -I'f Supplemental Information
TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST
Mechanical permit fees* are based on the value of the work
❑ New construction tddition/alteration/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*
)St1 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 46.75
Job site address: ld & U ��-' , t � 71 � S ' — ' ! (ducts/vents) Furnace 100,000 BTU ducts/vents ) 46.75
City/State /ZIP: 77 �' , ( sk ,. 2 Furnace 100,000+ BTU (ducts/vents) 54.91
Heat pump 61.06
Suite/bldg. /apt. no.: Project name: Duct work 23.32
Cross street/directions to job site: Hydronic hot water system 23.32
1 l (/".(---/:-.) n fl 5 Residential boiler (radiator or
!�� '� l eJ`� hydronic) 23.32
Unit heaters (fuel -type, not electric),
in -wall, in -duct, suspended, etc. 46.75
Flue /vent for any of above 23.32
Subdivision: Lot no.: Other: 23.32
Other fuel appliances:
Tax map /parcel no.: Water heater 23.32
DESCRIPTION OF WORK Gas fireplace/insert 33.39
C Flue vent for water heater or gas
C 4../77/.479-4_ G 5 k__ „ fireplace 23.32
Log lighter (gas) 23.32
Wood/pellet stove 33.39
Wood fireplace /insert 23.32
Chimney/liner /flue /vent "erROPERTY OWNER I ❑ TENANT Other: 23.32
, Environmental exhaust and ventilation:
Name: y! V _ 7 , QfS „ , ( A _� Range hood/other kitchen
eq
Address: ,~/� /0,09-i2_1<--- C Cl oth es d t 33.39
l���Q t^� �! ! jot ,. Clothes dryer exhaust 33.39
City /State /ZIP: i f ' ^ _ ? 0--i21--) Single -duct exhaust (bathrooms,
l CT ��' ? < toilet compartments, utility rooms) 23.32
Phone: 3) d ! ,.. Fax: ( ) Attic /crawlspace fans 23.32
❑ APPLICANT ❑ CONTACT PERSON Other: 23.32
Business name: Fuel piping:
$14.15 for first four; $4.03 for each additional
Contact name: Furnace, etc.
Address: Gas heat pump
Wall /suspended/unit heater
City/State /ZIP: Water heater
Phone: ( ) Fax: : ( ) Fireplace
Range 1 f
E -mail: Barbecue
CONTRACTOR Clothes dryer (gas)
Business name: Other:
MECHANICAL PERMIT FEES*
Address:
Subtotal
City/State /ZIP: Minimum permit fee ($90.00)
Plan review (25% of permit fee)
Phone: ( ) Fax: ( ) State surcharge (12% of permit fee)
CCB lic.: TOTAL PERMIT FEE ( Qv _ SO
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature : � �/ } , * Fee methodology set by Tri -County Building Industry Service Board - 5 4°—
Print name: �� /? (( ` r k lzPfBIt e : — G'? 4-7,13,
l:\ Building\ Permits\MEC_PermitApp_040113.doc 440 -4617T (I t/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\ Permits \MEC_PermitApp_040113.doc 2
` Information Notice to Owners About
''; C onstructi Responsibilities
Res onsibilities
�, (ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
• Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an em ployer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
• Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503 - 378 -4988.
• Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Em ployment
Department at 503 - 947 -1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503 - 945 -8091 or go to
http: / /www.oregon.gov /DOR /BUS /docs /211- 055.pdf for the appropriate forms.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503 - 947 -7815.
• Tax Withholding: Employers must withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1- 800 - 829 -4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance: As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough -in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
700 Summer St NE, Suite 300, PO Box 14140, Salem, OR 97309 -5052
Telephone: 503 - 378 -4621 — Fax: 503 - 373 -2007
Website Address: www.oregon.gov /ccb
f/property owner adopted 9 -23 -08 This Copy for Permit Applicant
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:
1if . ,, - A
Name CCB# Expiration Date
I will inform my general contractor that a II subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
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 ,d �� , I c` --- 7` j2
Print Name of Permit Applicant
,-- ... % , V-5....:, Lrc /3
Signature of Permit Applicant Date
Permit #: tt c ( 3- /70(3-(t ,1�
•!.
g'w , {,L) PA-e� _ .
Address: 7164P-4 .• >,,, . .:
Issued by: .k" Date: 41-(a-413 vi-i<
This Copy for Permit Offices