Permit 9
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
II Request for Permit Action
ri6ARD 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 taff
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.
❑ 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#: /17S7, jal
Site Address or Parcel#: l& cSi-✓ //,`g �L a
Project Name: ,DA
Subdivision Name: Lot#:
EXPLANATION: eii,, h/i fr„?„�)yiew r 7y,71-4,,eir• 5z 4hi 3 t,t/r--t/t°
iih4�,a/—ty r-t�e�1�'►e s ,Aj.r�62r ,p�1? -L� �eS`Ce,�/ %lam rs.uli - " vco.c,,h 1, .
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olv
eA-1 , 711./037— / ud/I 7
Signature: Date: 7 jg7A
Print Name: , 1-'7 7_
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Sys Admin: Date By Route to Records: Date ' /d 2. f By ,r,ed
Refund Processed: Date Ali BW1J Invoice Processed: Date By
Permit Canceled: Date�� pZ/ B3r4a Parcel Tag Added: Date By
I:\Building\Forms\RcgPermitAction_ 2051 .doc
Building Permit Application V
1 r
Residential eit '@.' FOR OFFICE USE ONI.V
City of Tigard R CE I V E , Received Permit No.:�7 : `„ ,
"s 13125 SW Hall Blvd.,Ti ard,OR 97223 Plan Review
i, g Plan Review
Phone: 503.718.2439 Fax: 503.598.1960 b p , { Date/By: Other Permit:
TIGARD
Inspection Line: 503.639.4175 CLL LULU Date Ready/By: funs. 61 See Page 2 for
Internet: www.tigard-or.gov Notified/Method: Supplemental Information
CITY OF TIGARD
TYPE OF WO*JILDING DIVISION REQUIRED DATA 1-AND 2-FAMILY DWELLING
Permit fees*are based on the value of the work performed.
0 New construction 0 Demolition
Indicate the value(rounded to the nearest dollar)of all
XAddition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ I-and 2-family dwelling 0 Commcrciallindustrial Valuation: $�/�Od
Aecesso Number of bedrooms:
ry buildin g ❑Multi-family ivfA
❑Master builder 0 Other: pe,tdcke4t CONxivi Rai, Number of bathrooms: 1i/A
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: I tinq 5vwi L l 60" pi New dwelling area: square feet
City/State/ZIP: Il la f-C,I. / (j r- 1d,9 _ Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: 1 538.9 Covered porch area: 520 square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
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
,+ DESCRIPTION j�OF WORK work indicated on this application.
Qehttt Curef. tl 'Q4 o. 'P rqa St it = p'E Zp' Valuation: $
R X 1 ` fl is t1.1 Existing building area: square feet
New building area: square feet
XPROPERTY OWNER ❑ TENANT Number of stories:
Name: 1_,„.ji"5 50,4Ac t Type of construction:
Address: 14 te,QtCI 5v.j it b 1 ' Occupancy groups:
City/State/ZIP: `Titi i O f- 11719.!l.9 Existing:
Phone:(5)3 ) I I 540 I Fax:( )
New:
APPLICANT ❑ CONTACT PERSON BUILDING PERMIT FEES*
� (� (Please refer to fee schedule)
Business name: E,t.erVt4I it (hs iY- -ti On
Structural plan review fee(or deposit):
:
r
Contact name: t�li5t
FLS plan review fee(if applicable):
Address: itt f3m ,-J l L iV 4{" e`
/ Oft- a 7-2� Total fees due upon application:
. 1
City/State/ZIP: Amount
received:
Phone:(5z 3 ) 9!S S 1_Q( Fax::( )
E-mail: PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
f v:ISr wt i ice"C OM
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name: C - I r2.cc Coi44j,-,,'C. )iL Submit two(2)sets of roof plan with connection details
"� / t and fire department access,along with the 2010 Oregon
a
Address: �r (.,0cq Solar Installation Specialty Code checklist.
City/State/ZIP: Permit Fee(includes plan review
ty pore t of- °VI215 $180.00
Phone: �,?� ;�-�� •-��(� ! and administrative fees):
(� ) Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.: 1 O 1 31`i
Total fee due upon application: $201.60
Authorized signature: -.. 'I'hls permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
j *Fee methodology set by Tri-County Building Industry
Print name: 1.,50 I s cem Date: I 21 t i 2020 Service Board.
I:\Building\Permits\l3UP-RESPermitApp.doc 02/24/2011 440-4613T(I 1/02/COM/WEB)