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9635 SW DURHAM ROAO �
CITY OF TIGARD PLUMBING PERMIT
PERMIT#: PLM2003-00179
y DEVELOPMENT SERVICES DATE ISSUED: 5/5/03
13125 SW Hail Blvd., Tigard, OR 97223 (503) 639-4171 PARCEL: 2S111CD-00500
SITE ADDRESS: 09835 SW DURHAM RD ZONING: R-4.5
SUBDIVISION- ALDERBROOK FARM JURISDICTION: T1�=
BLOC(: LOT:
MOBILE HOME SPACES:
CLASS OF WORK: NEW GARBAGE DISPOSALS: MOBILE HO PREVNTES:
TYPE OF USE: SF WASHING MACH:
FLOOR DRAINS; TRAPS:
OCCUPANCY GRP: R3 CATCH BASINS:
STORIES: WATER HEATERS:
_ FIXTUt' _ LAUNDRY TRAYS: SF' RAIN DRAINS:
SINKS: URINALS: GREASE. TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB/SHOWERS: SEWER LINE: 100 f`
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Remr,tks: Installation of 100'of sewer line to connect existing house to new lateral. Septic tank is to be pumped, filled
and inspected. ----
FEES _
Owner: Description Date Amount
SOLIS,GUSTAVO+ CAROL I PLUMB) Permit Fee 5/f:,103 $72.50
9835 SWDURHAM RD ITAX) W,;,Stt+te'l;ix 5/5/03 $5.80
TIGARD, OR 97224 — —
Total $78.30
Phone
Contractor:
A-AFFORDABLE SEPTIC SERVICE
PO BOX 1130
WILSONVILLE, OR 97070 REQUIRED INSPECTIONS _
Sewer Inspection
Phone : 503-969-9548 Insp existing/capped fixtures
Reg#: I W 151481 Final Inspection
This permit is issued subject to the regulations contained in the Tigard Municipal Code,
State of OR.
Sper:ialty 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 w thin 180 days of issuance, or if work is by
for more than 180 days. ATTENTION: Oregon law requires you to follow ru S adopted b the Oregon
i
Permittee Signature:
Issued By: _— _
Call (503) 639-4175 by 7:00 F.M. for an inspection needed the next business day
CITYOF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES 7ERMIT 't: SOIR2003-00149
13125 SW Hall Blvd., Tigard, OR 9T223 (503) 639-4171 DATE ISSUED: 5/5/03
SITE ADDRESS; 09835 SW DURHAM RD
PARCEL: 2 S 11'C D-00500
SUBDIVISION: ALDERBROOK FARMZONING: R--!.5
BLOCK: LOT: JURISDICTION: TIt
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection for existing house to newly installed lateral.
Owner. FEES____ _
SONS, GUSTAVO + CAROL
9835 SW DURHAM RG Description Date Amount
TIGARD, OR 97:'14 (SWUSA]SwrCounect 5/5/03 $925.00
1SWUSA]SwrConncct 5/5/03 $1,375.00
Phcne: ISWUSA]SwrConncct 5/5/03 $0.00
(SWINSP]Swr Inspect 5/5/03 $35.00
Contractor: ISWINSP]Sw-r Inspect 5/5/03 $0.00
Total $2,335.00
Phone:
Reg #:
Regi sired Inspections
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date isstied. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the siuE sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located,the installer shall purchase a"Tap and Side Sewer" Perm
Issued by: t �CLc�r(l: Permittee Signature:
Call (503) 639-4175 by 7:00 P.M. for an inspection needed the next business day
Building Fixtures
Plumbing Permit Application
P(,/-/ZQ�'��'Q/�J
CitCitAddress: 13125 SW Hall Blvd,Tigard,OR 97223
of Tigard 15' - ' ys Date received: Permit no.:
y Sewer permit nokoj*/Yf Building permit no.:
-
City of Tigard phone: (503) 639-4171 IlProject/appl. no.: Expire date:
Fax: (503) 598-1960 '�) Date issued: By: Receipt no.:
Land use approval: Case file no.: Payment type:
OF PERMIT
;J,oj,b
I &2 family dwelling or accessory U Commercial/industrial U Multi-family U Tenant improvement
Ne'x construction U ltltlition/niteration/replacement U Food service U Other:s 11 address: q8 -2,j -p(;,eki) Description Qty. hee(ea.) lotatl
Bldg. no.: Suite no.:
le" I-and 2-family dwellings only:
(includes 100 ft.for each utiliti,connection)
Tax map/tax lot/account no.: _ `__ SFR(I)bath
Lot: Block: Subdivision:
SFR(2)bath
Project name: SFR(3)hath
Cit /county: -T/E 2 p. ZIP: 9-7 Z 'Z Eachahc'itional bath/kitchen
Description and location of work nn premises: Site utilities:
"I r II(t At otrS E 7 Zjs1C S 5 It-J z' K L/MIFF Catch basin/area drain
Est.date ofcompletion/inspection: Drywells/leach line/trench drain
PLUMBING CONTRACTOR 1 routing drain ino. lin. It.)
Manufactured home utilities
Business name: �•, dVk— '�i ' ,_ `'� �riCE Manholes
Address: erre / 3 _ __ Rain drain connector
City: Ib'.%LSON I// L E State:p ZIP: 9 70 0 Sanitary sewer(no. lin. fl.)
Phone:_5C+3.94995c4 Fax: E-mail: _ Storm sewer(no.lin. Il.)
CCH no.: 13 N 8 p o Plumb.bus.reg.no: Water s,- vice no.lin.fl.
City/metro lic.no.: Fixture or item:
Contractor's representative signature: C Absorption valve
Back flow prever ter
Print name: jC/t C I I gate: Backwater valve
1 Basins/lavatory —
Name: 61"4 7,9 y' j e t I Clothes washer
Address: C! 3 S s tel .0 t. r+•a m /<, Dishwasher
Drinking fountain(s)
City: 7-161491). State: Q2 ZIP �/ 7 Z I Ejectors/sump -- _
Phone S"'j 7 / Sv Fax: E-mail: Expansion tank
OWNER ixture%sewer cap
Name(print): (TUS7, + 1 (` Dt f r/ r J Floor drains/floor sinks/hub _
_Mailin address: 9� 3.S' J t.U J_r t.'2 N i7 i// iL ID HoseGarbBibb l —
g Hose bibb _
City: 1 Cq?C _ State: 0PI ZIP: 9 7 Y t Y Ice maker _
Phone: S03 54f Fax: _I E-mail: Interceptor/grease trap _
owner installation/residential maintenance only: The actual installation Primer(s)
will be made by me or the mainteriance and repair made by my regular Roof drain.(commercial)
employee on the prop '1 o s per R ' hapter 447. _ Sink(s),basin(s),lays(s) _
Owner's si nature: o Date: r T�lf X63 Sump
Tubs/shower/shower pan
Urinal
Name: _ Water closet
Address: Watere— ate er
City: —State:_ ZIP: er:
�� 0-
Phone: -- Fax: TE-mail: Total
Nnt all jurisdictions ac creel t cards,plea.cell jurisdiction for more information. Minimum fee................ $ L2� `-U
aM Notice: This permit
i application Plan review(at— %) S
U Visa U MasterCard ex ircs if a rmit is not obtained
Credit card number:_ within 180 days after it has been State surcharge(8%).... S 'SW
_�
ap rn TOTAL. ......S �L.>3.�-
Name of car older u shown on erecta--rd
accepted as complete. """"""""
__ S
Cardholaer signature Amount 4404616(6MCOWI
PLUMBING PERMIT FEES:
PRICE TOTAL New 1 and 2-family dwelling- s only: T-
FIXTURES (individual) - QTY ea AMOUNT (includes all plumbing fixtures InPRICE TOTAL
Sink 16.60 the dwelling and the first100 ft. QTY (9a) AMOUNT
Lavatory 16.60 for each utility con action)_
One(1)bath $249.20
Tub or Tub/Shower Comb 16.60 _ Two 2 bath _ $350.00
Shower Only 16.60 Three 3 bath - $399.00
Water Closet _-, 16.60 - SUB TOTAL �-
Urinal 16.60 e%STATE SURCHARGE
Dishwasher 16.60 PLAN REVIEW 25%OF SUBTOTAL
Garbage Disposal 16.60 �_- TOTAL
Laundry Tray 16.60
Washing Machine 16.60
Floor Drain/Floor Sink 2" 16.60
3" 16.60 PLEASE COMPLETE:
4" 16.60
Water Heater O conversion O like kind 16.60 _ Quanti b I Work Performed
Gas piping requires a separate mechanical Fixture Type: New Moved Replaced Removed/
permit. Ca e-
MFG Home New Water Service 46.40 Sink
MFG Home New San/Storm Sewer 46.40 Lavato ~
Hose Bibs 16.80 Tub or Tub/Shower
Combing"on
Roof Drains 16.60 Shcwer Only
Drinking Fountain 1,6.60 Wwar Closet
Other Fixtures(Specify) 16.60 Urir al
Dishwasher
_ Garba c Disposal
Laund Room Tray _
Washing Machine
Floor Draln/Sink: 2"
Sewer-1 st 100' / 55.00 3" ''-
Sewer-each additional 100' 46.40 4"
Water Service-list 100' 55.00 Water Heater
Water Service-each additional 200' 46.40 Other Fixtures
S ecl,fy _
Storm&Rain Drain-1st 100' 55.00
Storm&,;gin Drain-each additional 100' 46.40
Commercial Back Flow Prevention Device 4640
Residential Backflow Prevention Device' 27.55
Catch Basin 16.fi0
Inspection of Existing Plumbing or Specially 62.50
Requested Inspections erlhr COMMENTS REGARDING ABOVE:
Rain Dain,single family dwelling 65.25 _
Grease Traps 16.60 �-
QUANTITY TOTAL -�`- --�
Isometric or riser diagram is requlred If - --'-'
OuantHy Total Is >9 -- --*SUBTOTAL
8%
- - -
8%STATE SURCHARGE -i- --` - -- - ---
"PLAN REVIEW 25%OF SUBTOTAL
Required only It fixture city total Is 1_9
TOTAL 5
*Minimum permit Its I572 50 896 state surcharge,except Residential BackBow
Prevention Device,which 36 25*8%state surcha%
"All New Commercial Buildings require 2 sets of plans with Isometric or riser
diagram for plan review.
IAdstslfnrmstplrr,-fees.doc 12/26/01
amass. RENOWN
October 25, 2002
rr w ,
Gustavo and Carol Solis CITY OF TIGARD
9835 SW Durham Road OREGON
Tigard, OR 97224
Dear Mr. And Mrs. Solis
The City of Tigard is preparing to install a traffic signal at the intersection of Durham
Road @ 98"' Avenue. The City would like to acquire a small area of land containing 60-
sq. ft. located in the southeast corner of your property. This area is needed to transition
from the existing wheelchair ramp to the new sidewalk that will be installed on 9811'
.Avenue. The City has offered $360 as just compensation for this right-of-way
dedication.
The City would also like to acquire a temporary construction easement to allow the
contractor to make a smooth transition from the back of the new sidewalk to the existing
ground level. The City has offered $465 as just compensation for this temporary
construction easement. Construction of the side valk will require pruning some of the
Existing trees and removal of four small trees. The City has offered $200 for each tree
for a total of$800.
The total offered compensation for the right-of-way dedication, the temporary
construction easement, and the loss of landscaping is $1,625. You have requested the
City install a sanitary sewer lateral from the existing sewer mainline to behind the new
sidewalk as part of this project. The City is willing to include this work in our project,
and have estimated your cost for the sewer lateral installation at approximately $1,500.
Please sign and return the dedication deed (notarized) and the temporary construction
easement form. The City will compensate you the difference between the offered
compensation of $1,625 and the cost of the sewer lateral based on the contractor's
actual bid.
Attached is the plan drawing showing the proposed sewer lateral location and also
showing how the new concrete driveway approach on 98u' Ave will be moved north to
meet the curb cut requirements. An asphalt driveway transition will be constructed to
blend tack into thr, existing driveway as shown on the plans. If you have any quest;ons,
please call me at 503-639-4171.
Sincerely,
u �
Michael Mills
Senior Engineering Technician
I\ENGW1KFWS0LISoHer2.DOC
13125 SW Hall Blvd., Tigard, OR 97223 (503)639-4171 TDD(503)684-2772 ------
SUMMARY OF FACTS
Location 9835 SW Durham Road, Tigard, OR 97224
Assessed Owner Gustavo and Carol Solis
Site Size 0.5 acres (21,731 sq. ft.)
Zoning R-4.5, Low-Density Residential
Assessed Value Land $90,090
Building $98,430
Improvements A single-story single-family dwelling, built in
1956, containing 2,052-5q. ft. of living space.
Present Use Single-family resi6once
Adjacent land Uses Single-family residential
Temporary _Construction A five foot strip of land adjacent to the
Easement Area easternmost property line. (Approximately 5
feet x 155 feet = 775 sq. ft.)
Right-of_Way Dedication An area of land containing 60-sq. ft. located in
the southeast corner of the property.
SUMMARY OF CONCLUSIONS
Total value of -Rioot-of-Way Dedication is allocated as follows:
(Land value) $90,090 divided by !area) 21,731 sq. ft. = (Unit value) $4.14 per sq. ft.
(Area) 60 sq. ft. x (Unit Value - negotiated) $6.00 = X60.00
Tree remove!: Four (4) trees @ $200 each = $00.00
Total value of the Temporary Construction Easement is allocated as follows:
(Land value) $90,090 divided by (area) 21,731 sq. ft. = (Unit value) $4.14 per sq. ft.
(Area) 775 sq. ft. x (Unit Value - negotiated) $6.00 x 5% x 2 years = $465.00
I�,�,N�Vr11KFMSUMMARYQf_f�T$=g935Uurh@m;pQ�
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79-
-/e
CITY OF TIGARD
1
EXPENDITURE REQUEST
This form is a multi-use form. Appropriate receipts and documentation must be attached to this form. Approved
request due Tuesday 8:00 AM to AJP for checks by Friday of the week that checks are paid.
VENDOR NO.: DATE: May 5, 2003
PAYABLE TO: Sewer Permit No. SWR 2003-00149 _ REQUESTED BY: Diane Jelderks
Sewer Connection Fee for account No.L
500-000-207000
Located: 9835 SW Durham Road
MISCELLANEOUS EXPENDITURES:
Date—� Description, Invoice No.,etc. Account No.^ Amount
5/5/03 Need Journal Entry from 210-6390-753.010 $ 925.00
Per Attached Agreement with City
Compensation for impact to private property
To construction signal at Durham&98`h
Gustavo&Carol Solis
Mileage$0.31 - -- -�--__
APPROPRIATION BALANCE: AS OF: SIGNATURE:
(Up TO$25.00)Section Manager Purch. Agent
($25.01-2,500.00) Division Manager _ 5 10; _
($2,500.01-7,500.00)Dept. [lead
($7,500.01-15,000.00)City Administrator
($15,000.01-?) Local Contract Review Board
FP17M FRX N0. May. 13 2093 04:00PM P3
�(
4 I
001
A-AFFORDABLE
p� SEPTIC-SERVICE
I •�^ P.O.BOX. 1,130
L� WILSONVILLE,OR 97070
(503)68249n PAX(=31 870.0779
CUSTQMfiR'S OROpR N0. PHONEDATE I
NAME
ADDRESS
--SOLD 6♦ CAS C.O,D.�CHAROG ON ACCt, MOM.RET'D. 11410 DUr
I
- Imo.-.__� � --T-
--- TAXI �
9ECEIVED DV TOTAL
Aii o rma and returnrd Oond9 MUST h►&rxornpgmWd bV this!;ill
Tm Raorger. THANK Y O U
soo•Moo of Raea.aorn
FROM : FRX Nri. May. 13 200, 03:59PM
c1canWate, 5crviccs
source Control Division
/5505WMdlsbriuhlighway Durham Wastewater 'Treatment Facility
NdMI)OON 31 LIQUID WASTE HAULER LOAD TICKET AND
twetuae-uon t
(so)se 1111i»csz HAULER INVENTORY SHEET
LIQUID WASTE HAULER LOAD TICKET
Company NAI-le;
USA Permit Numbs ti� �.
Number .s _ .- Truck License Number.. ._�j(L/ f-e
Date Liquid Pumped: _.�_�._/ �, -Off_ Time Pumped:
Date Durriped at USA: L=,1.Z..���' ._ _ Time Dumped: .__ ^
Approx, Gallons Pumped: j t�Q-.� Sample Taken: Yee X-No.
No - pH - 'I
LIQUID WASTE HAULER INVENTORY SHEET
Yes❑No❑ Receipts Attached (Please include all Information requested),
Customer Name-
Telephone Number:
Address: 9!3
Date Pumped; 6- �Z-CZ Galions Pumped!
Vessel Pumoed [ Septic Tank. [J Chemical Toilet: [J Other (Please List)
Customer Name: _ _ Telephone Number:
Address.
Date Pumped: _ Gallons Pumped
Vessel Pumped- ❑ Septic Tank 1-i Chemical Toilet ❑ Other (Please List) _.
Customer Name: _ Telephone Number: _
Address:
Date Pumped: Gallons Pumped:
Vessel Pumped: ❑ Septic Tank ❑ Chemical Toilet ❑ Other (Please List) _
Certification
I certify under penalty of law that the above information is true and correct to the best of my knowledge, and
further certify that the truck listed above contains only domestic sceptic tank or chemical toilet waste and does not
onntain process waste from either a com ercial or Industrial facility,
Print Name/Tltleq. �/�._,L-t, r , rrLf
Signature
RiwaM0.Si07 Wh to-Clean Wator servicta,Ytrilow-Industry
Form taot.r»
FROM FAX NO. May. 13 2003 03:59PM P1
P O Boy,1130 W0.w)nvWn,OR 41070 , ,
tibidable Septic
ph(%3)W 1929 rax(SM)57"779
.Se�Vice Inc.
Fax
Toa CR-1 of Tigard Fri Rick
F&M (503)6243681 Pagew. 2
Phones (503)6394171 Dates 5/13/2003
RW- Soptic Abandonment CC: Mike S.
❑Urgent ❑ For Review ❑Please Consent 0 Please Reply Cl Please Recycle
Attached is a copy of our pump receipt and dump ticket, The iexUting lank was filled with
clean%and.
Thank you,
Rick (SO3)969-9548
�a CITY OF TIGARD BUILDING INSPI'�CTION DIVISION
24-Hour Inspection Linc: 639-4175 Business Phone. 6394171
Date Requested: _ O A.M� P.M._ _-- MST:
Location: BUR
Tenant:— Suite: Bldg: MEC:,3 7-(15 k
Contractor: _ PLM: --
Owner. Phone: ELC:
ELR:
_ _ 31'I':
BUILDING BLDG(rnn't) PLUMBING CHANICA� ELECTRICAL SITE
Site Post/Beam Post/Beam
"os� Cover/Service Sewer/Storm
Footing Roof UndFI/Slab RI)igh-In Ceiling Water Line
Slab Framing Top Out Rough-In Uta Sprinkler
Foundation Insulation Sewer ct Reconnect Vault
13smt Damp Drywall Storm Furnace Temp Service MISC.
Masonry Ceiling Rain Drain A/C UG Slab
Shear/Sheath Fire Spkl,.'Alm Crawl/Found Dr Bent I', Low Volt
Approved Approved p1no ed Approved Approved
Appr/Sdwlk Not Approved Net Approved cd Not Approved Net Approved
( FINAL FI SAI, FINAL FINAL FINAL
0 Call for net do 0 Reinspection fee of S required before next inspection d Unable to Inspect
Inspector: _ Date: A— 7 Page'------of � I
CITY OF TIGARD MECHANICAL,
DEVELOPMENT SERVICES PERMIT
13125 SW HO Blvd., Tigard,OR 97223 (503)6394171 PERMIT #. . . . .. . . : MEC'97-0363
DATE ISSUEDr 09/26/?7
PARCEL: 26111CD-00500
SITE ADDPES9. . . : 09835 SW DURHAM RD
SUBDIVTSION— . : ALDERBROOK FARM ZONING: R-4. 5
BL-OCK. . . . . . . . — : L07.. . . . . . . . . . . . . JURISDICTION: TIG
—----------------------------------- -------------------------
�21.-ASS OF WORK. . :ALT FLOOR FURN. . . . : 0 EVAP COOLERS: 0
TYPE OF USE. . . . :SF UNIT HEA'rlRS. . : 0 VENT-
NT FANS. . . : 0
OCCUPANCY GRP. . :R3 VENTS W/O APPL.: 0 VENT SYSTEMS: 0
.":'DRIES. . . . . . . . : 0 BOILERS/COMPRESSORS HOODS. . . . . . . : 0
FUEL TYPES- --.--------- 0-3 HP. . . . : 0 DOMES. INCIN: 0
:GAS 3-15 HP. . . . : 0 COMML. INCIN: 0
MAX !NPUT: 0 BTU 15-30 HP. . . . : 0 REPAIR UNITS: 0
FIRE DAMPERS?. . : 30-50 0 WOODSTOVES. . : 0
GAS PRESSURE. . . 50+ HP. . . . : 0 CLO DRYERS. . : 0
NO, OF AIR HANDL IN13 UNITS OTHER UNITS. : 0
FURN ( 100K BTU: 2 <= 10000 c f m : 0 GAS OUTL-ETS. . 5
TURN ) =100K BTU: 0 10000 rfm: 0
Remarks : Installing gas furnace
Owner: FEES ----------------
EDGAR SOL-IS type amol.int by date recpt
9835 SW DURHAM RD PRMT $ 25. 00 B 09/26/97 97-299593
TIGARD OR 97224 5PCT 4; 1. 25 B 09/26/97 97-299593
Phone #:
Contractor:
PROGRESqIVE AIR
9708 SW 59TH
$ 26. 25 TOTAL
PORTLAND OR 97219
Phone #: 246-0900
Reg #. . : 000352
REQUIRED INSPECTIONS
This permit is issued subject to the regulations contained in the Gas Line I n s p
Tigard Municipal Code, StAp. of Ore. Specialty Codes and all other Mechanical Insp
applicable laws. All work will be done ir accordance with Final Inspection
approved plans. This permit will expire if work is not started
within 180 days of isstance, or if work is suspended for more
than 180 days. ATTENTION: Oregon law requires you to follow rules
adopted by the Oregon Utility Notification Center. Those rules are
yPt forth in OAR 95P-01-4010 through OAR 952-001-M. You may
obtain copies of these rules or direct questions to OW by calling
(503)246-9187.
1 By Permittee Signatmr-ei 41-11-
.++++++++++++++++++++++-�-++++++-J-4-++++-1-+++.+-+++++++-F+++.4-+++44.......................1-+
Call 639-4175 by 6:00 p. m. for inspections needed the next bi.tsiness day
............ +++++4-++4..................................#-+4..........................
Plan Check N
CITY OF TIGARD Mechanical Permit Application Recd By -777T-77D
13125 SW HALL BLVD. Commercial and Residential Oate Rec'd
TIGARD, OR 97223 Date to P E.
(503) 639-4171, x304 Date to DST
Print or Type Permit 0 10-n-V
Incomplete or illegible applications will not be accepted Called
Name of DevelowenuProlect Description
Table to Mechanical_Cale �~CITY PRICE I AMT
Job Stet Adore" nn A) Permit Fee -0- -0- 10.00
�k
Address ((. �5 -Sw if4o- Bailee, _
BidgeCtryfSlale Zj�\ 1.) Furnace to 100,000 BTU 6.00
r� il 0k Y7�zy including duds&vents
Nome(or name of busines 2.) Fumare 100,000 BTU+ _ 7.50
4c
Owner L 41(1, -So ( S including duds&vents
M*ilAb Address 3.) Floor Furnace 6.00
including vent
- Cxyrstate zip Phone 4) Suspended hAater,wall heater 6.00
or floor mounted heater _
Norne(or name of bunner-s) 5.) Vent not included in appliance permit 3.00
1
�c2�� c•
Occupant Mating Address 6.) Boiler or comp,heat pump,air Gond. 6.00
to 3 HP:absorb unit to 100K BUT"
CityiSt ne Z p Phone 7) Boiler or comp,heat pump,air Gond. 11.00
_ 3.15 HP:absorb unit to 500K BTU"
Contractor 8.) Boiler r o absorb heat
pump mil gond 1500
(Prior t0 e0 rC S jr VC 11, r
BTU-
Issuance Malin ddrese �� 9.) Boiler or comp,heat pump,air Gond. �Y 22.50
applicant l C7 3' �C�' �, / _ 30-50 HP:absorb unit 1-1.75mil BTU _
must provide all rstake Zip Phone 10.) Boiler or comp,heat pump,air Gond 37.50
rxontractor C,rtkl"c CCK Ce 7a i"� ,, Y& C)`r('( >50 HP;absorb unit 1.75 mil BTU"
license Oregon Const.Cont.Hoard LIc.I Exp Dae 11.) Air handling unit to 10,000 CFM 4.50
information if �:
expired in ,
COT COT Business Tax or Metro a Exp Dare 12) Air handling unit 10,000 CFM 7.5U
_database). s �:2y _ _ (,1, t V
Architect Nana 13) Non-portable evaporate cooler 4.50
or Mailing Address 14) Vent fan connected to a single duct 3.00
Engineer CdyBtate Zip Phone 15) Ventilation system not included in 450
_ appliance permit
Uesrnbe work New O Addition O Aflerabon O Repair O 16.) Hood served by mechanical exhaust 4.50
to be done Residential O Non-residential O
Additional (workDescription - -�--�- 17.) Domestic inpnerators 7 50
rile.", VS -�u#IACtCt /cf��fs -
(>nc4u4-1r• 'c cQrr+, r w[ 18-) Commercial or industrial type 30.00
Incinerator
Existing use of S F 19.) Repair units 4.50
building or property _
20) Wood stove 4.50
PRlposed use of /t 21.) Cbthec dryer,etc 4.50
building or property .S' f^ U _
22) Other units 4.50
Type of fuel-oil O natural gas LPG O electric O V 23) Gas piping one to four oaitlets � 2.00
I hereby acknowledge that I have read this application,that the :4 I More than 4-per outlets(each) .50
information given is correct,that I am the owner or authorized e lent of
the owner,that plans submtlted are,in compliance with Oregon State CITY SUBTOTAL
hr,
Signature of Owner/Agent Deb 9� � �' - 'SUBTOTAL --- r-fl
50,16 SURCHARGE
l�?^r y
ntact Person Name Phone PLAN 14EVIEW 25%OF SUBTOTAL
TOTAL
\dst\mechpmt doc (rev 9 'Minimum permit fee is S25+5%surcharge
-Residential A/C requires site plan showing placement of unit