13815 SW 115TH AVENUE-2 i Li U U U
13815 SW 115TH AVEME
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City of Tigard Mechanical Permf,,,, 21, 8 9
New Installation 0 Replace Relocation 0 Addition ❑ Alteration U DATE:
HEATING
CONTRACTOR OWNER
ADDRESS JOB ADDRESS.----------.-..---
PHONE APPLICANT-----------.--
Heat Input Rating(BTU per Hourl Vant Flue
FUEL OIL ❑ GAS [—I ELECT ❑ OTHER
ITEM FEE ITEM NO. FEE
For Issuance of Permit SEE.BELOW Each Air HandlLnq_Urit or Duct System 7.50
Naw-up to & incl. 100,000 TU 6. .— - Comwerciii 1T0o(1-§y-�m_ 7.50
NeyK � �.-7.50 Other EqLijpg!ent - Each 4.50
_19%PQ0 BUT's & ovel
Woodburning Stove 4.50 1 Trip Inspection 4.50
Wall-Floor- 6.00 Air Condition Compressor - up to& incl.3 H.P. --- 6.00 —
Vent System w/Fan 4.50 Air Condition Compressor-3.1 to 15.H.P.incl. 11.00
ft!alr- Heat Cooling 6.00
CITY BUIS!NESS LICENSE REQUIRED BY ALL CONTRACTORS OR SUB-CONTRACTORS !
PERMIT ISSUANCE 10.00
Comments: C
FEES
SUB-TOTAL
6 STATE Issued By
,25%1 -AN CHECK
TOTAL REC.
Signature of Applicant
City of Tigard
INSPECTION REQUEST
f o r r /Al
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INSPECTION TIME: �`��� �' PERMIT NO. :
DATE: IC ILV 7S7 DATE ISSUED : i Z I
OWNERS NAME : 7-0 P" h-0L4JN
ADDRESS:
�
CONTRACTOR :
TEST : Air ❑, Water❑ , Visual Laboratory p
RESULT: Approved 4 Disapproved ❑ , Pending []
SKETCH: AeegpreD rvtt ZVAI& r
i t I O 1 �-' o a�L �3 y1�G (I f t'✓1 S I TT Wit'-t./.1 w C I-1�• / zoo/7
/19
, 9
INSPECTOR DATE
COTE: Attach supplemental teat data hereto
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APPLICATION -- Si REET IMPROVEMENVEXCAVATION COPY TO:
U (WHITE)- FILE
ORDINANCE NO. 74-14 ❑ IBLUE) -INSP.
[J (YELLOW) -OTHER AGENC
(INSTRUCTIONS ON SCPARATE SHEET) [] (PINK) APPLICANT
APPROVED ❑ APPLICATION NO.:
NOT APPROVED ❑ CITY OL' TIGARD, OREGON FEE AMT.: S -
PENDING FEE. PMT, CITY HALL. RECEIPT NO.: --- —
PENDIN'-SECURITY G PUBI.ICWORKS DEPARTMENT BY �__
PENDING AGENCY ''OK'' ❑ Application and Progress Record MAINTENANCE BOND #
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REOUIRtO ❑
ANNUAL 11
PENDING VARIANCE ❑ _- - EXPIRATION DATE; --------/
I
PERMIT NO.: _�—_.. DATE ISSUED: - ------ BY: --
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT L..- n L J �, �� CJI ITS I u 1''C•?
--
---- -- NAME T..ODRESS i I i CITY ..,, I ' -- --_- PHONE -
CONTRACTOR _ -
-- --NAME �_-�� �--ADDR FSS CITY - --PHONE PLANS BY BY _ ----
��--�-NAME -----�-----T--ADORkSS _ �_s. CITY NONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E
DOLLARS _
FOR OFFICE USE: -_.--. nMIN.
(2) EXCAVATION DATA: 0.02 x s--_._.__.-= S._-__-: _
STREET DESCRIPTION PROGRESS & INSPECTiON STATUS
NAME SURFACE CUT CUT CUT MATERIAL. IINSTAI.LED ITEM DA'Z'E REMARKS--/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 8 ()UANTITY
-� S'rREET
OPENED
-- INSPEC-
R TION
Q
U -
ESTIMATED STREET OPENING DATE: 5
ESTIMATED STREET CLOSING DATE: ED
STREET
(3) SECURITY NO. __ .-- SECURITY AMT.: e-- CLOSSD _
SURETY CO.: _ _ FINAL
CERTIFIFD CHECK U CASH ❑ BOND n INSPEC• _ ...
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL SPECIAL.PROVISIONS/CONDITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
-
I 1 I I
I
(5) NOTE. THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAV JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGR..ES TO DEP03IT THE REQUIRED RECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATION3 PER,-!`,ENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE DATE
U •�
ADDRESS ,� �X i c��- // tom` PERMIT NO. eS'
PERMIT CHARGE none
Oio JER �Jte—,- CONNECTION FEE 0-
PAID
PAID B Y
TYPE OF RUIIDING _ '� DATE CONNECTED
SERVICE RATE INSPECTION FEE ,�lS
CONTRACTOR �a ����1 �%� � PAID BY S A T E
SI7_E OF CONNECTION _ ��� ASSESSMENT PAID ___