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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 I Request for Permit Action /..'-9/9r de) TIGARD 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 1ity Staff Check(V)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. (1---q- REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). E INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: /-1-c A/ ©o i9 y Site Address or Parcel#: Project Name: Subdivision Name: Lot#: EXPLANATION: [O-E --A , / 6 ee, — .0&2 /:u -- as f y3 /9 6-rc4--- Signature: Xr ��yJ Date: d277 Print Name: �Ll4ivL C7,--AA12-4_S' 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. Route to Sys Admin: Date By Route to Records: Date? A.3 By ,4 O Refund Processed: Date /I/4 By O) Invoice Processed: Date By Permit Canceled: Date 0/21/ , By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_r20518.e oc 0 Building Permit Application fl :-5/iI / Residential l ` 01 Mk 01 MI I SI.0y1.1 REU n City of Tigard �� na1eB• y d$-l7ZOZ/ PermitNo.:,(�(dT2O2/Gd19� 13125 SW Hall Blvd.,Tigard,OR 97223 6�: 1 Plan Review = Phone: 503.718.2439 Fax: 503.598.1960 i. � Date/By: Other Permit: T I G A KD Inspection Line: 503.639.4175 Date Ready/By: ! See Page 2 for Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information RUILDING DIVISION TYPE OF WORK REQUIRED DATA:I-AND 2-FAMILY DWELLING 0 New construction Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all ❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. I'.: 1-and 2-family dwelling 0 Commercial/industrial Valuation: $ 3,500 ❑Accessory building 0 Multi-family Number of bedrooms: 0 Master builder 0 Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: 15160 SW 81st Ave New dwelling area: square feet City/State/ZIP: Tigard, OR 97224 Garage/carport area: 493 square feet Suite/bldg./apt.no.: Project name: Bella Meadows Subdivsion Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet REQUIRED DATA:COMMERCIAL-USE CHECKLIST Subdivision: Bella Meadows Lot no.: Permit fees*are based on the value of the work performed. Tax map/parcel no.: 2S112CB Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. Removal of garage in southwest corner of property. Valuation: $ Existing building area: square feet New building area: square feet X PROPERTY OWNER 0 TENANT Number of stories: Name: Mark Vukanovich Type of construction: Address: 4931 SW 76th Ave.,#360 Occupancy groups: City/State/ZIP: Portland, OR 97225 Existing: Phone:( 541)350-1060 Fax:( ) New: rg APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES* (Please refer to fee schedule) Business name: Big-Vuk LLC Structural plan review fee(or deposit): 87If Contact name: Mark Vukanovich J.- FLS plan review fee(if applicable): Address: lJ St.„,) --tot' Awe . RY 3100 City/State/ZIP: 6r on, OR Total fees due upon application: �O C� 4 n� �� Q�a Amount received: Phone:( 541) 720 3734 3Sp-lOb-d Fax::(_ ) E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES* Commercial and residential prescriptive installation of CONTRACTOR roof-top mounted Photo Voltaic Solar Panel System. Business name: Submit two(2)sets of roof plan with connection details Olson Bros Excavation and fire department access,along with the 2010 Oregon Address: 4515 NW Silver Leaf Dr Solar Installation Specialty Code checklist. City/State/ZIP: Portland, OR 97229 Permit Fee(includes plan review $180.00 and administrative fees): Phone: 503-531-0529 Fax:( ) State surcharge(12%of permit fee): $21.60 ecB lie.; 69865 Total fee clue upon application: $201.60 Authorized signatur ' This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: (� Date: *Fee methodology set by Tri-County Building Industryt3CY \ � — � � v� C`!.. �� ;l� Service Board. I:1Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)