Permit Support Document W
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEV 0 I
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Ti G A R D 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 E Contractor ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) e y A/ 771-14- 41,97
Mailing Address: /5' Al' y 4E- sr-
City/State/Zip: /JO 2lr'l i� / Q,� 97-2_a3
Phone No.: �a � �f-- /7 (a
PLEASE T ACTION FOR THE ITEM(S) CHECKED (✓):
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 #: /'l2S7'�,H/6e-96_3
Site Address or Parcel #: f I/y9 1ZJ /01 7a Aft
Project Name: /7
Subdivision Name: Lot #: ,F30z)
E�XrPLANATION: Avvvi Cr',t ,/ GU' ern/ (fly, i1-�` �-Q (.6L, /n ,
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Signature: Date: ��j j
Print Name:
Refund Policy �U
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 (a //0l By .: Route to Records: Date ' / 7 y 1 By,jO
Refund Processed: Date P ,4L/ B 1 C Invoice Processed: Date By
Permit Canceled: Date 6/1/ / By4 Parcel Tag Added: Date By
I:A Building\Forms\RegPermitAction_120518.doc
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TIGARD
City of Tigard
August 13, 2021
Cynthia White
5215 N Yale St
Portland, OR 97203
Re: Permit No. MST2021-00203
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14992 SW 109th Ave
Project Name: White
Job No.: N/A
Refund Method: ® Check#240268 in the amount of$438.33.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
El Trust account"deposit" receipt in the amount of$
Comment(s): Permit created in error as MST for residential project and was replaced
by commerical permit BUP2021-00124. Refund 100% of plan review fee paid.
If you have any questions please contact me at 503.718.2430.
Sincerely, �7 Q
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
0 City of Tigard
TIGARD 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 forPermit 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: Cynthia White DATE: 8/10/2021
5215 N Yale St
Portland, OR 97203 REQUESTED BY: Dianna Ornelas
BT
TRANSACTION INFORMATION:
Receipt#: 434497 Case#: MST2021-00203
Date: 5/24/2021 Address/Parcel: 14992 SW 109th Ave
Pay Method: CreditCard Project Name: White
EXPLANATION: Permit created on MST2021-00203 as residential and was replaced by BUP2021-00124
as commercial project.
REITND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund R
Example: Building Permit lee Example: 2300000-43 1 1 4 1 $Amount
Plan Review
230-0000-43106 $438.33
TOTAL REFUND: $438.33
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager 490 �Z,y,�� _
If under$25,000 Department Manager /�
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: I rf%` ,1
I.\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
I 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: White
Site Address: 14992 SW 109TH AVE A c Ft AJJ
Receipt Number: 435810 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M ST2021-00203 $-438.33
Total: $-438.33
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240268 DHOWSE 08/13/2021 $-438.33
Payor: Cynthia White
Total Payments: $-438.33
Balance Due: $438.33
Page 1 of 1
CITY OF TIGARD RECEIPT
I� 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: White
Site Address: 14992 SW 109TH AVE
Receipt Number: 434497 - 05/24/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2021-00203 Plan Review 230-0000-43106 $438.33
Total: $438.33
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7788132 PUBLICUSERO 05/24/2021
$438.33
Payor:
Total Payments: $438.33
Balance Due: $0.00
Paae 1 of 1 _
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1Building Permit ApplicatioFil ' ; ° . ;r2
Residential FOR OFFICE USE ONLY
City of Tigard Received5 //2O2i I�6V7—{-c/<-f-004-+'a1
Date/By: 2 . Permit No.:
1111 a 13125 SW Hall Blvd.,Tigard,OR 97223 asp �O Plan Review
8 Phone: 503.718.2439 Fax: 503.598.196t1✓(1I OF f ' . .' 0 Date/By: Other Permit:
1 t[;C,It D Inspection Line: 503.639.41754c3U L ONG)+w+ t Date ReadyBy: tom: See Page 2 for
Internet: www.tigard-or.gov Notified/Method: .� Supplemental Information
TYPE OF WORK REQUIRED DATA:1-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
g]Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $ 45,000.
D4 1-and 2-family dwelling ❑Commercial/industrial
❑Accessory building ❑Multi-family Number of bedrooms: 2
❑Master builder 0 Other: Number of bathrooms: 1
JOB SITE INFORMATION AND LOCATION Total number of floors: 1
Job site address: 14992 SW 109TH AVE New dwelling area: square feet
city/state/ZIP: Tigard, OR. 97224 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: Covered porch area: square feet
Cross street/directions to job site: Canterbury Lane Deck area: square feet
top of hill on 109th Ave., Canterbury Woods Condo's Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: 8800 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.: 251-1 OAD equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
minor kitchen & Bath remodel Valuation: $
Existing building area: square feet
New building area: square feet
El PROPERTY OWNER 0 TENANT Number of stories:
Name: Cynthia White Type of construction:
Address: 5215 N Yale St Occupancy groups:
city/State/ZIP: Portland, OR. 97203 Existing:
Pam:(503)351-1736 Fax:( ) New:
El APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES*
(Please refer ro fee schedule)
Business name: owner
Structural plan review fee(or deposit): T3 33
Contact name:
FLS plan review fee(if applicable):
Address:
City/State/ZIP: Total fees due upon application:
Amount received:
Phone:( ) Fax::( )
E-mail: cyndiw( precisionfirst.com PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted Photo Voltaic Solar Panel System.
Business name: Owner Submit two(2)sets of roof plan with connection details
and fire department access,along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City/State/ZIP: Permit Fee(includes plan review $180.00
and administrative fees):
Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.: Total fee due upon application: $201.60
Authorized signature: 144��K,� . ..-_ This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Cynthia White Date: 5-! p i� -2.l *Fee Service Booard.gy set by Tri-County Building Industry
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Dianna Ornelas
From: Cyndi White <cyndiw@precisionfirst.com>
Sent: Monday, August 9, 2021 11:58 AM
To: #Building Permit Technicians
Subject: RE: BUPP2021-00124, 14992 SW 109, White
Follow Up Flag: Follow up
Flag Status: Completed
Categories: Julie
Warning!This message was sent from outside your organization and we are unable to verify the sender.
Thank you Julie,
Please send the refund check for the review overpayment to my current residence at 5215 N.
Yale St., Portland, OR. 97203
Cyndi White
503-351-1736
From: #Building Permit Technicians [mailto:TigardBuildingPermits@tigard-or.gov]
Sent: Monday, August 09, 2021 8:59 AM
To: Cyndi White <cyndiw@precisionfirst.com>
Subject: BUPP2021-00124, 14992 SW 109,White
Hello Cyndi
Per our conversation by phone this morning, attached please find the water meter fixture unit worksheet and plumbing
permit application,that should be submitted to tigardbuildingpermits(a tigard-or.gov for processing. As I mentioned
before, the plumbing permit cannot be obtained by your plumbing contractor through our online permit system.
The permit has been placed on the table in the conference room just to the right as you enter the first set of doors to
the permit center. You may pick it up Monday through Thursday between the hours of 8:00am and 5:00pm.
Thank you and please let us know if you have any questions.
Julie Drinkwater
Permit Technician
City of Tigard Building Department
13125 SW Hall Blvd
Tigard,OR 97223
503-718-2804
Due to an increased demand for services, please expect longer wait times for responses to emails,voice messages and building
inspections. Requests for permit status may not be responded to until the permit is ready to issue. Other requests deemed non-
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essential,such as fee estimates, may take longer to respond. In the meantime, please view this quick guide on how to submit
common service requests.
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."
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