Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
111 AFR 2 5 2i2 ,,
Request for Permit Action CITY OF IGARD
1 I t;,\it l 1 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigAgt9W DIVISION
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 .j,City Staff
Check(✓)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):
N. CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: P a('ja,a ^ co U�(
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot#:
EXPLANATION: CC-AP a,e,a, — oD G Ylof reC
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Signature: C��ZJ�✓" Date: L( 4 02
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Print Name: WtQA\\
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 4 22 By 1'vA Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 4\21`22 By IN Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc
K Building Permit Application
Residential ii , e
iV
City of Tigard ✓I? 0 202 Received L ,(�INg ` Date/By: � G//�� /" PermitNo.: �T ��r�1'I�
13125 SW Hall Blvd.,Tigard,OR 97223 tan Review C6'�'
s Phone: 503.718.2439 Fax: 503.598.1960 ,.A i Y Or I EGA ate/By: Other Permit:
I.1 i {t I l Inspection Line: 503.639.4175 3I f I LDI N G DIVI SI1.i Ready/By: Jmis: lg See Page 2 for
Internet: www.tigard-or.gov Notitied/Method: Supplemental Information
TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING
0 New construction 0 Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Igi Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $ /
7,1 1-and 2-family dwelling 0 Commercial/industrial
J��cl
❑Accessory building 0 Multi-family Number of bedrooms: a
❑Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors: r
Job site address: /t 6,0 / ,,/z4,L ,PRNew dwelling area: square feet
City/State/ZIP: ! C,,y f 6A/W I c L1 ?7.2.2V. Garage/carport area: e square feet
Suite/bldg.apt.no.: Project name: V®vit16 � ' 6),J061 Covered porch area: ,ff square feet
Cross
�street/directions to job site: 14,vime/l-�5L DR, TO Deck area: square feet
c Ig e' w5 uj Ati f0 iJz e1 M AJO DP, Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision:$ 15Rf�.tCL0 /,®, ( , Lot no.: 19 Permit fees*are based on the value of the work performed.
51 1 C I���� indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK /� ,/ work indicated on this application.
PPPLAce, t� "5�!�iLl& tiariv o& S 4Orsnes , (,(Tjt Valuation: $
66,1-C _ QF. / omr 62,7,4 k.r- �6u r ,5 _. A 1 itri 2 •,p) Existing building area: square feet
V� New building area: square feet
Et PROPERTY OWNER 0 TENANT Number of stories:
Name: f..4.4`'7A43trTli tiodiA.Y, Type of construction:
Address: /bl(O® Ski //Vali i v-4D .DR. Occupancy groups:
City/State/ZIP: s
I1Cn412r� ; I) a��Q �7o� Existing:
Phone:( ) Fax:( ) New:
.4 APPLICANT 12 CONTACT PERSON BUILDING PERMIT FEES*
,Business name:c43 $otr-t_o I=0 (Please refer to fee schedule
Structural plan review fee(or deposit): �E e °-1
a,
Contact name: „XM V.co aitioER S
� FLS plan review fee(if applicable):
Address: /3t.13 Coax 7-R 7/ Gi_elv ,4 A/C-Total fees due upon application:
City/State/ZIP: )rzei t ak 97.303
Amount received:
Phone:(SO3)\ ? 1 S - '/ye Fax: :( )
- JJ
� L PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
E-mail: ri 3 b uTy_de s Q .c �'GIS-• it /
Commercial and residential prescriptive installation of
CONTRACTOR roof-top mounted PhotoVoltaic Solar Panel System.
Business name: (43 J3LL LDeRs Submit two(2)sets of roof plan with connection details
Are-- and fire department access,along with the 2010 Oregon
Address: /3//3 O'piaTI29 cLE� Ave/1te- Solar Installation Specialty Code checklist.
City/State/ZIP: YExzE� ®9 97 �' Permit Fee(includes plan review $180.00
q t and administrative fees):
(Sfj Phone: ) 7 j�G Fax:( ) '
����� State surcharge(12%of permit fee): $21.60
CCB lic.: Total fee due upon application: $201.60
Authorized signature: This permit application expires If a permit is not obtained
within 180 days after it has been accepted as complete.
*
Print name: 1 A4- yo C� Date: It¢�1p� Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)