Permit Support Document (2) r) t rj
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT'' y
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Re quest for Permit Action P/2'/ze 1
Tic;A R l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.Agard-or.gov
RECEIVED
TO: CITY OF TIGARD MAY 18 2020
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 CITY OF TIGARD
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerr 4a ertON
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) G d 13 i' L(11&/,'.J6--
Mailing Address: p 40 .e x „2_
City/State/Zip: 5.7- /441-'1 L.- / O ci 9 2/3 7
Phone No.: . O 3 ,-"s i — f y l -7
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Pi CANCEL/VOID PERMIT APPLICATION.
MO' FUND PERMIT FEES (attach copy of original receipt and provide explanation below).
II INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: FPS - &DO/Z
Site Address or Parcel#: /eiaz 7 542 !A✓Gt 4Gl e,7 l s-
Project Name:
Subdivision Name: p Z-/i`t / 14 Lot#:
EXPLANATION: p p� oil-6,0 de__ 40,,,, t 0/.cc .Lcnr .S ?Irk".
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. ! -PS 14-_,/1-.4/i--. Ty' has 41-to, ac(06-0,l 7t /4S7z)17-001'`t.
Signature: ~t!��"rv� g-/Date: ` 0
Print Name: J /'Z /7j;hie-wait/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. "( .0 f G� , A r,
/�0I 3 T 6 7 s rzautas 7a ti S /
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Route to Sys Admin: Date /dl.I,e) By Route to Records: Date if rzie By
Refund Processed: Date /� � B Q Invoice Processed: Date By
Permit Canceled: Date �p/�/2.) Byi) 0 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 518.d/6c
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TIGARD
City of Tigard
September 2, 2021
G&B Plumbing
PO Box 92
St. Paul, OR 97137
Re: Permit No. FPS2020-00012
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14037 SW Walnut St
Project Name: Fern Ridge,Lot 2
Job No.: N/A
Refund Method: ® Check#240415 in the amount of$86.06.
❑ Credit card "return"receipt in the amount of$
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): Permit was created in error as work was completed under master permit
MST2019-00144. Fees in the amount of$193.96 were transferred to master permit;refund
difference of$86.06.
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
11111
City of Tigard
T I G A R D 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: G&B Plumbing DATE: 8/27/2021
PO Box 92
St. Paul, OR 97137 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 429085 Case#: FPS2020-00012
Date: 4/21/2020 Address/Parcel: 14037 SW Walnut St
Pay Method: CreditCard Project Name: Fern Ridge,Lot 2
EXPLANATION: Permit created in error and scope of work was completed under MST2019-00144. Fees
in the amount of$193.96 transferred to MST;refund difference of$86.06.
IIMPUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount_
Cash Over 100-0000-48001 $86.06
I
TOTAL REFUND: $86.06
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager (e4A,,t..,/e...,...._)
If under 25 000 Department Manager
er P g
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: `Pl y/rii By: .eL''
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
i
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Fern Ridge, Lot 2
Site Address: 14037 SW WALNUT LN /1.�FC A an
Receipt Number: 436289 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2020-00012 $-86.06
Total: $-86.06
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240415 DHOWSE 09/04/2021 $-86.06
Payor: G&B Plumbing
Total Payments: $-86.06
Balance Due: $86.06
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
• -- 503.639.4171
T t,..;t I
Project Name: Fern Ridge, Lot 2
Site Address: 14037 SW WALNUT LN alb CjiAn- ..
Receipt Number: 429085 - 04/21/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2020-00012 Cash Over 100-0000-48001 $86.06
Total: $86.06
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6291006 PUBLICUSERO 04/21/2020 $280.02
Payor:
Total Payments: $280.02
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Fern Ridge, Lot 2
Site Address: 14037 SW WALNUT LN
Receipt Number: 429085 - 04/21/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2020-00012 Cash Over 100-0000-48001 $86.06
Total: $86.06
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6291006 PUBLICUSERO 04/21/2020 $280.02
Payor:
Total Payments: $280.02
Balance Due: $0.00
Page 1 of 1
q
CITY OF TIGARD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
1 FGARD
Project Name: Fern Ridge, Lot 2
Site Address: 14037 SW WALNUT LN
-11Z 9--0 S r-Y---
Receipt Number: 429551 - 05/28/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2020-00012 $-193.96
Total: $-193.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Fund Transfer DHOWSE 05/28/2020 $-193.96
Payor:
Total Payments: $-193.96
Balance Due: $0.00
I
Page 1 of 1
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
COMMUNITY DEVELOPMENT Permit#: FPS2020-00012
T I G A R.D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/21/2020
Parcel: 2S 104BC 10500
Jurisdiction: Tigard
Site address: 14037 SW WALNUT LN
Project: Fern Ridge,Lot 2 Subdivision: FERN STREET SUBDIVISION Lot: 2
Project Description: Fire sprinklers permit due to site grade.
Contractor: G&B PLUMBING&SONS INC Owner: K5 URBAN PROPERTIES&MANAGEMENT
PO BOX 92 PO BOX 25571
ST PAUL, OR 97137 PORTLAND, OR 97239
PHONE: 503-868-1417 PHONE: 503-292-9344
FAX:
FEES
Description Date Amount
Specifics: Fire Protection System Permit-RES 04/21/2020 $246.45
12%State Surcharge-Building 04/21/2020 $29.57
Type of Use: SF Info Process/Archiving-Lg$2.00(over 04/21/2020 $4.00
Class of Work: ALT Type of Const: VB 11x17)
Occupancy Grp: R-3 Height: ft
Stories: 2
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density: 0 Design Area: 0
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $280.02
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $0.00
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503. 2.1987 or .800.3 .2344.
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Building Permit Application
Fire Protection System FOR OFFICE USE O\I.I
City of Tigard RECEIVED Received
: aa Permit No.:�,Q 1
• —
IN 13125 SW Hall Blvd.,Tigard,OR 9 Plan Review I r
I Phone: 503.718.2439 Fax: 503.598.19601 AN Al ry 202o Date/By: ...2.0 Other Permit (37—y j.1...,ry�/Lill
T I l A R D Inspection Line: 503.639.4175 •
Jt11Y 1 Date Ready/By: , / I` sa See Page 2 for (s.
Internet: www.tigard-or.gov �Y OF ��GARD Notif d/M�eehhod.�/// �C/�('J Supplemental Information
,ri
TYPE OF VSQIODI REQUIRED DATA:1-AND 2-FAMILY DWELLING
1W 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 ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application re_
I-and 2-family dwelling ❑Commercial/industrial Valuation: :, ,- �
❑Accessory building IDMulti-family Number of bedrooms: A /C#- z2Z
ElMaster builder El Other:
Number of bathrooms: $ YA/70
JOB SITE INFORMATION AND LOCATION Total number of floors: ?/
Job site address: '4 V(' } sky) W 0 h4't .i New dwelling area: 343(1 square feet
City/State/ZIP: � 0 ILGarage/carport area: 44 L square feet
Suite/bldg./apt.no.: V Project name: ,$t Ay. gA& €- Covered porch area: 31 0 square feet
Cross street/directions to job site: Sw **vibe, ru&c L T L trw C E Deck area: square feet
u Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: (14,01.c)e- Lot no.: ?j Permit fees*are based on the value of the work performed.
Tax map/parcel no.: 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.
Valuation: $
Existing building area: square feet
New building area: square feet
PROPERTY OWNER ❑ TENANT Number of stories:
Name: l<5 U a lo cv, 1 Ore�vi,-t'�t„S A �.". p,,wct— Type of construction:
Address: Too WOX Z ✓s 1 Z �" Occupancy groups:
City/State/ZIP: iO tAkCvU DNC 41A.Z't-3 Existing:
Phone:(S3) Z�� 63 4 4 Fax:( )
v�+ New:
%APPLICANT 0 CONTACT PERSON NOTICE
Business name: g V.``p. 4 . %Lc A. k,p DE S All contractors and subcontractors are required to be
Contact name: C.���S L L�L� licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 1 O 90 )L 25 5}I jurisdiction in which work is being performed.If the
City/State/ZIP: V0A.A`C•^ik 0 V- 6\ Li g applicant is exempt from licensing,the following reasons
q apply:
Phone:(S,03) 241 2. `5A I Fax::( )
E-mail:
/ j CC��`CONTRACTOR BUILDING PERMIT FEES*
Business name: L�.C Q y 1�n �� (Please refer to fee schedule)
Address: � pl 4�% G\Z j Permit fee:
City/State/ZIP: r '�q�?L bi/ ( pt-t34- State surcharge(12%of permit fee):
FLS plan review(40%of permit fee):
Phone:(Sc, ) 136 5 ,, ax: 3 s.1q (5444 (Due upon application submittal.)
CCB lic.: 18 �3� Total permit fees:
1 Amount received:
Authorized signature:
�( This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: --V\ \ try,. Date:) 2142,DZ�
* Fee methodology set by Tri-County Building Industry
Service Board.
rtBuilditgtPemvts\FPS-PemiitApp_03 16.doc 440-4613T(I 1/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2-Supplemental Information
Describe work to be done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
0. New system Number of sprinkler heads: Number of alarm devices:
❑ Addition or El 1-10 heads: Affidavit required and El 1-5 devices: Affidavit required and
Alteration (3)copies of sketch showing area (3) copies of sketch showing area
to existing of work within building structure of work within building structure
system
El 11+heads: Plan review required and ❑ 6+ devices: Plan review required and
(3) sets of plans. (3) sets of plans.
Additional description of work:
Type of System (Complete A,B, C or D as applicable):
A.) Commercial Sprinkler
Sprinkler Type El Wet El Dry
Additional Standpipes
Information: Sprinkler Supply Line El Yes ❑ No
Hazard Group
Density
Design Area
K.Factor
Sprinkler Project Valuation: $
B.) Type I- Hood Fire Suppression System
Hood Project Valuation: I $
C.) Fire Alarm
Submittal shall Battery Calculations El Yes
include: Individual Component ❑ Yes
Cut Sheets
Fire Mann Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
1 2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal(see A,B&C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage(see D above): $
State Surcharge (12%of permit fee): $
FLS Plan Review(40%of permit fee): $
TOTAL: $
1:\Building\Permits\PPS_PermitApp_031016.doc 2
Dianna Ornelas
From: Julie Drinkwater
Sent: Wednesday, May 27, 2020 8:31 AM
To: Felipe Perez
Cc: Dianna Ornelas
Subject: Fern Ridge, Lots 1 &2
Attachments: Invoice.pdf
Hello Felipe
The revision for Fern Ridge, Lots 1 & 2, for the fire sprinkler systems, are now ready. Because the fees for the
system for Lot 2, have been voided and will be transferred from the fire protection safety permit to the master
building permit, no additional fees will be due. The balance due for Lot 1, is $261.18. Attached please find the
invoice for your review.
To pay the fees online, you can go to our website: https://aca.accela.com/TIGARD/Default.aspx. From there,
click on the Building tab, enter the permit number in the Record Number field, and click Search.
Please let us know once the fees have been paid so that we can make the permits ready for you to pick up.
Thank you
Julie Drinkwater
Permit Technician Assistant
City of Tigard I Building Department
13125 SW Hall Blvd
Tigard, OR 97223
503-718-2804
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
1
Fee List Page 1 of 1
Crtt�Gg.-- /2 F(A14A
SWR2019-00138-Starbucks
Menu Add Delete Void Invoice Invoice&Pay ReCalc Help
Fee Calc.Factor: Job Value(Contractor)$0.00 v Fee Total $27,176.50
Showing 1-3 of 3
❑ Invoice Date Fee Item Quantity Unit
Assessed
❑ 217957 05/02/2019 Sewer Connection Fee 4.81 Dwellings
❑ 217958 03/20/2020 Sewer Connection Fee 3 Dwellings
❑ 217959 03/20/2020 Cash Over 9,776.5 Dollar Am
Page 1 of 1
https://ay.accela.com/portlets/fee/feeList.do?mode=list&module=Building 5/21/2020