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Permit Support Document (2) UPI II TIGARD City of Tigard November 8, 2019 Flow Rite Plumbing 19902 SW Jay St Beaverton, OR 97006 Re: Permit No. PLM2019-00412 Dear Applicant: The City of Tigard has processed a refund for overpayment of permit fees on the above referenced permit for the following: Site Address: 12176 SW Ames Ln Project Name: Borelli Job No.: N/A Refund: ® Check#233833 in the amount of$7.00. 0 Credit card "return" receipt in the amount of$ . 0 Trust account"deposit"receipt in the amount of$ . Notes: Scope of work changed resulting in an overpayment of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, , "(:"2 Dianna Howse Building Division Services Coordinator Enc. I:\Bwlding\Refund mnss t l la°bi 9 503.639.4171 TTY Re ay: s5� .684.2772 • www.tigard-or.gov• ri 3 City of Tigard T 1 c n 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: Flow Rite Plumbing DATE: 11/1/2019 19902 SW Jay St Beaverton, OR 97006 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 426379 Case#: PLM2019-00412 Date: 10/10/2019 Address/Parcel: 12176 SW Ames Ln Pay Method: CreditCard Project Name: Borelli EXPLANATION: Per applicant's request as scope of work changed resulting in overpayment. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Cash Over 100-0000-48001 $7.00 TOTAL REFUND: $7.00 APPROVALS: SIGNATURE A E: If under$5,000 Professional Staff "CV 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 FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: 7/2/2./ By: O I:\Building\Refunds\RefundRequest.doc x 09/01/2010 4CITY OF TIGARD RECEIPT II13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Borelli Site Address: 12176 SW AMES LN Receipt Number: 436190 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00412 $-7.00 Total: $-7.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 233833 DHOWSE 09/03/2021 $-7.00 Payor: Flow Rite Plumbing Total Payments: $-7.00 Balance Due: $7.00 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T1Cp 1RD Project Name: Borelli Site Address: 12176 SW AMES LN !�2f�1`✓�-� Receipt Number: 426379 - 10/10/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00412 Water Service 230-0000-43101 $62.54 PLM2019-00412 Backflow Preventer 230-0000-43101 $31.27 PLM2019-00412 12% State Surcharge- Plumbing 100-0000-24001 $11.26 PLM20 1 9-0041 2 Cash Over 100-0000-48001 $7.00 - Total: $112.07 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 5648181 PUBLICUSER112 10/10/2019 $112.07 Payor: Total Payments: $112.07 Balance Due: $0.00 Page 1 of 1 Plumbing Permit Application Building Fixtures RECEIVED FOR OFFICE: USE ONLY City of Tigard Received G I� DateB a3 (9 '--PermitNc 13125 SW Hall Blvd.,Tigard,OR 97223 OCT 2 3 2019 y �� t'`��i9-®a yip-' S Plan Review Phone: 503.718.2439 Fax: 503.598.1960 DateBy. Other Permit No.: TIGARD Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready/By Juris Ed See Page 2 for Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method. Supplemental Information TYPE OF WORK FEE* SCHEDULE _ IDNew construction ❑Demolition For special information use checklist Description I Qty. I Ea. Total ®Addition/alteration/replacement ❑Other New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 SFR(2)bath 437.78 ® 1-and 2-family dwelling ❑Commercial/industrial CIAccessory building ❑Multi-family SFR(3)bath 500.32 ------ Each additional bath/kitchen 25.02 ❑ Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address:12176 SW AMES LN. Catch basin or area drain 18.76 Drywell,leach line,or trench drain 18.76 City/State/ZIP:TIGARD, OR 97224 Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: Project name: Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer(no.linear ft.:_) Page 2 Storm sewer(no.linear ft.: ) Page 2 Water service(no.linear ft.: 70) 1 Page 2 62.54 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 1 31.27 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 25.02 REPLACE WATER SERVICE LINE AND BACKFLOW PREVENTER Dishwasher 25.02 /t V "L h o-'/9 00 'WA 71J I9 7Z.t1 T Drinking fountain 25.02 L-//V F---T- a, e</ 7r.. L/ g- 7) 7 o f fr., Ejectors/sump 25.02 • ❑ PROPERTY OWNER 09`, A et9e -7 L'? . ANT Expansion tank 12.51 Name: f / -W Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 2 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02 Business name:AKA ENTERPRISES, INC dba FLOW-RITE PLUMBING Medical gas(value:$ ) Page 2 Primer 12.51 Contact name:DEAN SPENCER Roof drain(commercial) 12.51 Address:19902 SW JAY STREET Sink/basin/lavatory 25.02 City/State/ZIP:BEAVERTON, OR 97003 Solar units(potable water) 62.54 Phone: (503 )914-7285 Fax: :(503 )214-8423 Tub/shower/shower pan 12.51 E-mail:flow-riteplumbing@live.com Urinal 25.02 Water closet 25.02 CONTRACTOR Water heater 37.52 Business name:same as above Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal 93.81 Phone:( ) Fax:( ) Minimum permit fee: $72.50 CCB Lie.:196936 Plumbing Lie.no.:PB 1194 Plan review (25%of permit fee) 6,uybyState surcharge(12%of permit fee) 11.26 Authorized signature: TOTAL PERMIT FEE 105.07 Print name: Pe'aThis permit application expires if a permit is not obtained within 180 days Collen K. Date:10/23/19 after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. i.\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-46167(10/02/COM/WEB) tA. Af e1 2"e,-YZ. //1---7"--7 C?.J 7- ,-:'' '