Permit Support Document (163) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 0
R114 ale q ue /a/
st for Permit Action
1 l c A R r) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE ACTION FOR THE ITEM(S) CHECKED (1):
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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: /P-J g /(.._-
Site Address or Parcel #: /0/3e) (5J �Ucy-7.) Air.",,4744
Subdivision Name: a Lot #:
EXPLANATION: - � -�^ ffe, - Gifoc.r,p a":). Ycv-
r�rc �1ce)--ocit36 .� Aid es .7 •s,,.., -P
Signature: _ Date:
Print Name: ,2aJv f'n.' e�`'e -_-r ' .
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to S s Admin: Date ' B T Z�� Route to Records: Date / / - B
Refund Processed: Date /1//9' By 7til, Invoice Processed: Date By
Permit Canceled: Date 7 .2/ /4, By OW- Parcel Tag Added: Date By
I:A Building\Forms\RegPermitAction_092314.doc
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FOR OFFICE ESE ONLY
City of Tigard Received 5 3i ,�
Date/B Permit enn r �+
� 13125 SW Hall Blvd.,Tigard,OR 97223 RECFJN Plan Revie � ���`��C}�`
Phone: 503.718.2439 Fax: 503.598.1960 •cher Permit:
Inspection Line: 503.639.4175 Date/By:
71 G R I) p 2.016 Date Ready/ �' � is: See Page 2 for
Internet: www.tigard-or.gov I) Notified/Met d:
WI g4( 7 ,21 /� ^1_., /' pp mental Information
Su le
s . - a„,` x .` - ., �' �: - ... ,.5, w ; it F ?. 'ai'” .'z, ilt'1 iY " 4 '`d
l� . t a Mechanical permit fees*are based on the value of the work
❑New construction ft Addition/alteratt i.a,
performed.Indicate the value(rounded to the nearest dollar)of all
mechanical materials,equipment,labor,overhead,and profit.
❑Demolition ❑Other:
m Value $ v
❑ 1-and 2-family dwelling L. Commercial/industrial 0 Accessory building For special information use checklist.
❑Multi-family 0 Master builder 0 Other: Description
Ea. Total
t- t : :t `r P'C r- r,. Heating/cooling:
Air conditioning s_
,. ' r, P, / , . 1 g 46.75
Job site address: ' . Furnace 100,000 BTU(ducts/vents) 46.75
City/State/ZIP: (MAO al.... 'C i-V1'7') Furnace 100,000+BTU(ducts/vents) 54.91
U L Heat pump 61.06
Suite/bldg./apt.no.: I Project name: ✓)��
Duct work 23.32
Cross street/directions to job site: Hydronic hot water system 23.32
4i "C Residential boiler(radiator or
4'4") 1440' i)nwWcrl' S /!�," WbishA
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: I Lot no.: Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater
23.32� = : ,"-.44.-..-' Gas fir ]ace/insert
. .. . ..' s.,• 0�1 :`Oep 33.39
�-(� {� ,�` �' Flue vent for water heater or gas
1W 1 ,� tikre'1 I ' _ •� "rV '^'` fireplace 23.32
VI/ IAA., l//�i-0 � Log lighter(gas) 23.32
Y�" 'v ' Wood/pelletstove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32
', Other: 23.32
c : a. *ito : �� " ," ' = - A� Environmental exhaust and ventilation:
Name: t, 0 t)JU^l Range hood/other kitchen
Address: [0197D N .0 4411-01111 equipment I 33.39
Clothes dryer exhaust 33.39
City/State/ZIP: 7160-(1.4) O& , t *-2jy'yj Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 23.32
Phone:(yds) fi ll-- t ,,,5 t Fax:( ) Attic/crawlspace fans 23.32
_ i .._. . lieZ(3 1I 3 N _ . . Other: 23.32
Business name: 1 " _ `L� L -c\sN 1 43 1_ Fuel piping:
\� � 19 ,2w^ `�1 $14.15 for first four;$4.03 for each additional
Contact name: W l W(,lam"` Ml Furnace,etc.
Address: -7j-I— , 3-1w71.) !71r Gas heat pump
Wallsuspended/unit heater
City/State/ZIP: 0100.-11,...4.440 06--_ 1'24—+ Water heater
Phone:(�- )) 41,1- 11 Fax::( ) Fireplace
d'/ TY L4 4l /p-1 /�' Range
E-mail: Ll G,7 G (�VhA�L l<,P�tri
Barbecue
' ' ; Clothes dryer(gas)
Business name: 0)l.L.v �' j f L i_— Other:
Address: (� h s,34 1 I ANTCAI.PERMIT 1 « r. __
Subtotal
City/State/ZIP: V AW 'tr14_ Oik, 1 .1;44)1 Minimum permit fee($90.00)
5(0r7) 1b 1, 'D Fax:( ) Plan review(25%of permit fee)
(
Phone: State surcharge(12%of permit fee)
CCB lic.: 2 TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
AlliP1 ` days after it has been accepted as complete.
Authorized signa * Fee methodology set by Tri-County Building Industry Service Board
Print name: ;0`t A•" 1\1\41/(0\ Date: 5- -' ! >`•'
1:\Building\Permits\MEC_PermitApp_040113.doc 440-4617T(I 1/02/COM/WEB)