Permit q
TIGARD
City of Tigard
September 10,2021
Elemental Energy LLC
1339 SE 8th Ave, Suite B
Portland, OR 97214
Re: Permit No. MST2020-00295
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 8915 SW Bellflower St
Project Name: Fyodorov
Job No.: N/A
Refund Method: ® Check#240479 in the amount of$251.50.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as job was cancelled after permit issued because
owner would not respond to communication from applicant to begin work. Refund 80%of
permit fees paid.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
IIIII
City of Tigard
i 1GARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Elemental Energy LLC DATE: 9/6/2021
1339 SE 8th Ave, Suite B
Portland, OR 97214 REQUESTED BY: Dianna Omelas
TRANSACTION INFORMATION:
Receipt#: 431725 Case#: MST2020-00295
Date: 11/9/2020 Address/Parcel: 8915 SW Bellflower St
Pay Method: CreditCard Project Name: Fyodorov
EXPLANATION: Per applicant's request as job was cancelled after permit issued and owner would not
respond to communication from contractor to begin work. Refund 80% of permit fees.
'REFUND t'WGAMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example 2300000-43104 $Amount
Building permit fee 230-0000-43104 $144.00
Electrical permit fee 220-0000-43103 80.56
12%State Surchage 100-0000-24001 26.94
TOTAL REFUND: $251.50
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager .)
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
r.
Case Refund Processed: Date: er ,/,2,/ By: 0
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Fyodorov
Site Address: 8915 SW BELLFLOWER ST
Receipt Number: 436380 - 09/10/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2020-00295 $-251.50
Total: $-251.50
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240479 DHOWSE 09/10/2021 $-251.50
Payor: Elemental Energy LLC
Total Payments: $-251.50
Balance Due: $251.50
Page 1 of 1
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CITY OF TIGARD RECEIPT
i j 13125 SW Hall Blvd.,Tigard OR 97223
• - 503.639.4171
T I+.;i, I' I)
Project Name: Fyodorov
Site Address: 8915 SW BELLFLOWER ST ® /2-1
FLLAZIS
Receipt Number: 431725 - 11/09/2020 S'0 `b
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2020-00295 Solar Photovoltaic System 230-0000-43104 /egg, cz) $180.00
MST2020-00295 Info Process/Archiving-Sm$0.50(up to 230-0000-43135 $4.00
11x17)
MST2020-00295 12%State Surcharge-Building 100-0000-24001 /7• $21.60
MST2020-00295 5 kva or less 220-0000-43103 J '• 5 $100.70
MST2020-00295 12%State Surcharge-Electrical 100-0000-24001 9`Co (o $12.08
/ eL) AS/. �0 $5
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7010839 PUBLICUSER34873:11/09/2020 $318.38
Payor:permits@elements
Total Payments: $318.38
Balance Due: $0.00
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Page 1 of 1
RECEIVED
City of Tigard a COMMUNITY DEVELOPMENT DEPARTMENT ��R 2 Z�ZI
Request for Permit Action CITY OF TIGARD
l k i;\R l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or. LDING DIVISION
1
TO: CITY OF TIGARD
Building Division
I D
13125 SW Hall Blvd.,Tigard,OR 97223 `7 �P /Z�r 4 6
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-o .gov
FROM: ❑ Owner ❑ Applicant )C❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ELEMENTAL ENERGY LLC
Mailing Address: 1339 SE 8TH AVE SUITE B
City/State/Zip: PORTLAND, OR 97214
Phone No.: 503.967.5786
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
X[ CANCEL/VOID PERMIT APPLICATION.
X❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MST2020-00295
Site Address or Parcel #: 8915 SW BELLFLOWER/ ST TIGARD OR 97224
Project Name: P ye .dine V
Subdivision Name: APPLEWOOD PARK NO. 2 Lot#: 75
EXPLANATION: Customer stopped responding to all communication after permits were issued. Er
We reached out many times with no response, so the job was cancelled. j- ,r0 [el
Signature: c-, .._. Date: 4/26/21
Print Name: Molly Beckel
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 request z
2. All refunds will be returned to the original payer in the form of a check via US postal service.
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ere
3. Please allow 3-4 weeks for processing refund requests. " -6y /`/% ff , e y/ y. ✓� e d � ��
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fZe_ ro w..-7e - mD . .s{v = �D . /y
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FOR OFFICE USE ONLY 4.
2-1--1-
Route to Sys Admin: Date' 2(o 'Zl By \c) Route to Records: Date 9 /C 2_/ By4 0
Refund Processed: Date `J/O f Z4 By Invoice Processed: Date By
Permit Canceled: Date 9/4,jzi By''� Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1!0518.doc
Building Permit Application E-IOI7 i2,p �1
Residential FOR OFFICE USE ONLY
2020
O C T Received srzoZo 9
City of Tigard DateBy: /OJI �` / PermlN°"� 2 S
r 13125 SW Hall Blvd.,Tigard;OR 97223. ` ' „"'-'d Plan Review A
Phone: 503.718.2439 Fax 503 598.1960 Uatc,uy. 0 �!� ki Other Fermi:
T IGARD Inspection Line: 503 639.4175 t "U Date Ready/By � ® See Page 2 for
Internet: www.tigard-or.gov Notified/Method: V( / � »> Supplemental Information
EltiA(1'-'" Ct4v- siirlt
-ii-i- ar _ TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DW I I I IN Z.
❑New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
2 Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION; work indicated on this application.
Valuation: $ 3,800
(NI 1-and 2-family dwelling ❑Commercial/industrial
ElAccessory building ❑Multi-family Number of bedrooms:
4 ❑Masterbuilder ❑Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION 1 ,,`,-'-F.. - Total number of floors:
Job site address: 8915 SW BELLFLOWER ST New dwelling area: square feet
City/State/ZIP: TIGARD, OR 97224 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: Fyodorov Solar Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
Subdivision: Lot no.: Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
1 DESCRIPTION OF WORK work indicated on this application.
3.8 kV AC Solar Photovoltaic Prescriptive Roof mount Valuation: $
Existing building area: square feet
New building area: square feet
® PROPERTY OWNER 1 ❑ TENANT Number of stories:
Name: Sergei Fyodorov Type of construction:
Address: 8915 SW BELLFLOWER ST Occupancy groups:
city/state/zIPTIGARD, OR 97224 Existing:
Phone:( ) Fax:( ) i New:
VI APPLICANT q CONTACT PERSON BUILDING PERMIT FEES*
(Pleasedule)
Business name: ELEMENTAL ENERGY vieweref(rr deposit):
Structural plan review fee(or deposit):
Contact name: CHRISTINE STAMPER 503-522-9190 (CELL) FLS plan review fee(if applicable):
Address: 1339 SE 8TH AVE STE B
Total fees due upon application:
City/State/ZIP: PORTLAND, OR 97214
Phone:( ) 503-967-5786 Fax: :( ) Amount received:
E-mail: PERMITS@ELEMENTALENERGY.NET PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR( roof-top mounted Photovoltaic Solar Panel System.
Business name: ELEMENTAL ENERGY Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address: 1339 SE 8TH AVE STE B Solar Installation Specialty Code checklist.
City/Stale/ZIP: PORTLAND OR 97214 Permit Fee(includes plan review $180.00
and administrative fees):
Phone:( ) 503-967-5786 Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lie.: 195141
Total fee due upon application: $201.60
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: CHRISTINE STAMPER Date: *Fee methodology set by Tri-County Building Industry
10/07/2020 Service Board.
1:\Building\Permits\BUP-RESPetmitApp.doc 02/24/2011 440-4613T(lI/02/COM/WEB) 3 rd r
se
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE USE ONLY
City of Tigard ReceivedDateB Permit No.:
n 13125 SW Hall Blvd.,Tigard,OR 97223 at
g Associated permits:
Phone: 503.718.2439 Fax: 503.598.1960
24-Hour Inspection Line: 503.639.4175 ❑ Electrical ❑ Plumbing 0 Mechanical
TIGARD
Internet: www.tigard-or.gov ❑ Other:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW Yes I No N/A
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. 0 El ❑
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. ❑ ❑ ❑
3 Verification of approved plat/lot. 0 ❑ ❑
4 Fire district approval required. Name of district: 0 0 ❑
5 Septic system permit or authorization for remodel, Existing system capacity . ❑ ❑ ❑
6 Sewer permit. 0 0 0
7 Water district approval. ❑ ❑ ❑
8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑
9 Erosion control ❑plan ❑permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 ❑
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state 0 0 0
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
copyright violations exist.
11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if 0 0 0
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements
and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction
indicator;lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and
surface drainage.
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size ❑ ❑ ❑
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 0 ❑
furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- 0 ❑ ❑
floor,wall construction,roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings
and foundation,stairs,fireplace construction,thermal insulation,etc.
15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels, ❑ 0 0
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and locations;for non- ❑ ❑ ❑
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing ❑ ❑ ❑
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑
systems,see item 22,"Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ 0 ❑
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. ❑ 0 0
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required ❑ ❑ 0
for four or more appliances.
22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or ❑ ❑ ❑
architect licensed in Oregon and shall be shown to be a.plicable to the pro-ect under review.
JURISDICTIONAL SPECIFICS
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". ❑ 0 , ❑
24 Two(2)sets each are required for Items 16, 19,20 and 22 above. 0 ❑ ❑
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. ❑ ❑ ❑
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. ❑ ❑ 0
27 "Drawn to scale"indicates standard architect or engineer scale. ❑ ❑ ❑
28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard ❑ 0 ❑
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 ❑ 0
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, ❑ ❑ ❑
including decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
1:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Electrical Permit Application --'"I FOR OFFICE USE ONLY 1
7 Received
City of Tigard2020 Date/By: Permit#: MS%2o20-00296
13125 SW Hall Blvd.,Tigard.,OR 97223 e
-, Plan Review Related Permit#:
' ■ ` Phone: 503.718.2439 Fax:. 503 598 1960 s t`{?�\s"i-...1Date/By:
Inspection Line: S03.639.4175 n `; s 1 1 Ready DateBy: ...ill ® See Page 2 for
TIGARD Internet: www.tigard-or.gov Notified/Method: I `� Supplemental Information
TYPE OF WORK ....PLAN.REVIEW
❑ New construction E Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more ❑Building over three stories.
❑ Demolition ❑Other: where the available fault current ❑Marinas and boatyards.
CATEGORY OF.CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
til 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑ Multi-family ❑Master builder ❑Other: ❑Fire pump. 0 Installation of 150 KVA or
JOE MK 7NFO4MATION AND.LOCATION - "im ❑Emergency system. larger separately derived
0 Addition of new motor load of system.
Job 4: Job site address: 8915 SW BELLFLOWER ST 100HP or more. ❑"A"."B".°'t-z",`1-3",
Cl /$rate/ZIP: 0 Six or more residential units. occupancy.
City/State/ZIP: Tigard, OR 97224 ❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: Project name: Fyodorov Solar 0 Hazardous locations, 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: FEE SCHEDULE . „ a,
Description i Qty. l Each I Total I ^
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4 1
Tax map/parcel#: Ea.add'I 500 sq.ft or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential
3.8 kW AC Solar Photovoltaic Prescriptive Roof Mount install,
(with above sq.ft.) 75.00 2
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
.. Renewable Energy ❑ See Page 2
® PROPERTY OWNER - ❑. TENANT =a Services or feeders installation,alteration,and/or relocation
Name: Sergei Fyodorov 200 amps or less 100.70 2
Address: 8915 SW BELLFLOWER ST 201 amps to 400 amps 33.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP: Tigard, OR 97224 601 amps to 1,000 amps 301.04 2
Phone:( ) Fax:( ) Over 1,000 amps or volts 552.26 2
Email: Temporary services or feeders installation,alteration,and/or
relocation
Owner installation: This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
APPLICANT [�CONTACT PERSON Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: ELEMENTAL ENERGY above service or feeder fee,
each branch circuit 7.42 2
Contact name: CHRISTINE STAMPER, 503-522-9190 (CELL) a Fee for branch circuits without
Address: service or feeder fee,first 56.18 2
1 'i'i9 SF, RTH AVF, STE B branch circuit
City/State/ZIP: Each add'/branch circuit 7.422
PORTLAND 97214 Miscellaneous(service or feeder not included)
Phone:(50' )967-5726 Fax: :( ) Each manufactured or modular 6784 2
dwelling,service and/or feeder
Email: PERMITS@ELEMENTALENERGY.NET Reconnect only 67.84 2
CONTRACTOR '". Pump or irrigation circle 67.84 2
Business name: ELEMENTAL ENERGY Sign or outline lighting 67.84 2
'2 (t 7 B Signal circuit(s)or limited-energy ❑ See Page 2 2
Address: 1339 SE 8TH AVE E STE panel,alteration,or extension.
City/State/ZIP: Each additional inspection over allowable in any of the above
PORTLAND O1� 97214 Additional inspection(1 hr min) 66.25/hr
Phone:( 503)D967-5786 IiFax:( ) Investigation(1 hr min) 90.00/hr
Email: PERMITS@ELEiMLN'1ALEi1VERGY,NE�I' Inspectioal plant(1hrmin) 78.18/hr
Cnspections For which no fee is 90.00/hr
CCB Lie.: i 95141 Electrical Lie.: C Cl1228 Suprv.Lie.: 4894S specifically listed(1 hr min)
g ELECTRICAL PERMIT FEES
�
Suprv.Electrician signature,required: ) Subtotal.
Print name: David Gehrke Date: 10/07/2020 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
Authorized signature: TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name: CHRISTINE STAMPER Date: 10/07/2020 days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\Building\Permits\ELC PermitApp_ELR_ERE.doe Rev 06,17/2015 440-4615T(11/05/COM/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCIIEEtt
Description I QV.
Fee for all residential systems combined: S75.00 Renewable
I raal I
y electrical energy systems:
Check Type of Work Involved: 5 kva orless 1 100.70 2
5.01 to 15 kva 133.56 2
n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25,01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
❑ Garage Door Opener* >100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
I I Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 7.42 3
❑ Vacuum Systems* >100 kva—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
Other: Each additional inspection is 66.25/hr 1
---- charged at an hourly(I hr min)
Inspections for which no fee is 90.00/hr
specifically listed(%hr min)
COMMERCIAL WORK ONLY: ; ELECTRICAL PERMIIF,
Fee for each commercial system: $75.00 Subtotal(Enter on Page I):
* Number of inspections allowed per permit
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
n Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
Li Instrumentation
Ti Intercom and Paging Systems
I I Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
n Outdoor Landscape Lighting*
Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:\Building`Permits\ELC PermitApp_ELR_ERE.doe Rev06/17i2015