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Permit Support Document y.. .. .. t Wad City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 4,A q Rh . Request for Permit Action TIGARD 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 aey Staff Check(1)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#: -" 1a r1 CGS. Site Address or Parcel#: /d1 re () 147 .,-, > Project Name: ed Subdivision Name: Lot#: EXPLANATION: Zi ,,,_ 02.4,,,,,, frei ,l i S2LAL r' 1cir �, -ev" ,,i ,,p it„ 7y 17-4 E1 41-w /cdrrje .f...Cl 71z) cc-)c,'s 7Sw., .M Z I #1)c4r,i7�` ..rn s -- 1/1—c�jr 5-- Signature: 7 i Date: �'/ih/� Print Name: �i/ 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 70-4as CI. D i71; FOR OFFICE USE ONLY Route to Sys Admin: Date r-i By ..4 Route to Records: Date 5' / !I' B 4xfIl' Refund Processed: Date‘ph f ' By 0 Invoice Processed: Date ` lJ By Permit Canceled: Date / 6 By p Parcel Tag Added: Date By I:\Building\Forms\RegPemritAction_ 20518.doc Plumbing Permit Application Building Fixtures FOR OFFICE LSE o\I.Y III City of Tigard g Date/By:D y Received III j! ®J1'�� "f' Permit No. rr `. .00 / y 13125 SW Hall Blvd.,Ti ard,OR 972. 3 iq / Plan Review • Phone: 503.718.2439 Fax: 503.598.1960 Date/By: Other Permit No.: T t:A k Inspection Line: 503.639.4175 APR 24 2 01 J Date Read/B Juris: ® See Page 2 for Internet: www.tigard-or.gov y y' A Notified/Method: Supplemental Information TYPE OF WOII:I I OF TIGARD FEE* SCHEDULE ❑New construction LIT bt1,I,DANG DIVISION For special information use checklist Description Qty. 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 ❑ 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78 ❑Accessory building El Multi-familySFR(3)bath 500.32 ❑Master builderEach additional bath/kitchen 25.02 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AM) LOCATION Site utilities: Job site address: [0 p 0 V .ot- s+ Catch basin or area drain 18.76 D n 1-7,L Drywell,leach line,or trench drain 18.76 City/State/ZIP: i (/f t fL "0I 2 1 Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.:V I Project name: .V'^r'n u 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.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 1^,�'1 �•,,, Clothes washer 1 25.02 )�;L),Z hk �'C 4 Q ) to,(.Q .Q ((.l1 C(01-141DS W(i et) Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 PROPERTY OWNER I 0 TENANT Expansion tank 12.51 Name: ut< 0-t tY1 yi Sk.,6,u Fixture/sewer cap 25.02 � 1 D S LV I I oil n, Floor drain/floor sitik/ttub 25.02 o Address: \ 11 1iC Garbage disposal 25.02 City/State/ZIP: `j i cud 1 A 0 (',--)223 Hose bib 25.02 ti Phone:( 5(s) '2-r =1S 0 2 t- `l Fax:( ) Ice maker 12.51 0 APPLICANT 0 CONTACT PERSON Interceptor/grease trap 25.02 Business name: c 41 R b`k)-(.. Medical gas(value:$ ) Page 2 Contact name: Primer12.51 Roof drain(commercial) 12.51 Address: Sink/basin/lavatory 25.02 City/State/ZIP: Solar units(potable water) 62.54 Phone:( ) Fax::( ) Tub/shower/shower pan 1 12.51 //.5 E-mail: Urinal 25.02 Water closet 25.02 CONTRACTOR Water heater \ 37.52 3 7.5) Business name: f/]^,/Afe_f- Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal 7�; Phone:( ) Fax:( ) Minimum permit fee: $72.50 CCB Lic.: Plan review (25%of permit fee) P►umbing Lic.no.: State surcharge(12%of permit fee) ` . O) Authorized signature: 1 j�� l� j -f0 Li) TOTAL PERMIT FEE W it.OP Print name: Al� ," Date: 155 1) '1 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\PLMU-PermitAoo.dor 10/01/09 nen n<rc rirnin�iiv.n.�,2nr IIp TIGARD City of Tigard June 24, 2019 Choung Ang 12070 SW 119th Ave Tigard, OR 97223 Re: Permit No. PLM2019-00165 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10080 SW Katherine St Project Name: Phou&Ang Job No.: N/A Refund Method: ® Check#232384 in the amount of$84.06. ❑ Credit card"return" receipt in the amount of$ 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): Plumbing work added to existing permit (MST2019-00115) so a separate plumbing permit was not required. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov IN 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 Requestfor 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: Choung Ang DATE: 6/17/2019 12070 SW 119`h Ave Tigard, OR 97223 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 423016 Case#: PLM2019-00165 Date: 4/24/2019 Address/Parcel: 10080 SW Katherine St Pay Method: CreditCard Project Name: Phou&Ang EXPLANATION: Plumbing should have been added to existing permit MST2019-00115 per Branden Taggart. Refund 100%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Iuilding Permit Fee Example: 2300000-43104 $Amount Plumbing Permit 230-0000-43101 $75.05 12%State Surcharge 100-0000-24001 9.01 TOTAL REFUND: $84.06 APPROVALS: SIGN URES DATE: If under$5,000 Professional Staff 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 "� � .�!a � � T � x, `� �,��y�, ��y) r n?n'�d"�.�`,- �� 1��#�"�� fr`�"�a'`; .<:: a ,. .,. :. ' f a 71 vrfrm# '.Y,-w r.z Ir a„�.ae+rs a,� •` i Case Refund Processed: Date: I 5'1'y�l By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 II CITY OF TIGARD RECEIPT ,111111 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: PHOU Site Address: 10080 SW KATHERINE ST Receipt Number: 423019 - 04/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00165 $-84.06 Total: $-84.06 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 32292D DHOWSE 04/24/2019 $-84.06 Payor: Choung Ang Total Payments: $-84.06 Balance Due: $0.00 Page 1 of 1 lillAi CITY OF TIGARD RECEIPT ,. $ . .. 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 THOARD Project Name: PHOU Site Address: 10080 SW KATHERINE ST Receipt Number: 423016 - 04/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00165 Clothes Washer 230-0000-43101 $25.02 PLM2019-00165 Tub/Shower/Shower Pan 230-0000-43101 $12.51 PLM2019-00165 Water Heater 230-0000-43101 $37.52 PLM2019-00165 12% State Surcharge- Plumbing 100-0000-24001 $9.01 Total: $84.06 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 32292D BTAGGART 04/24/2019 $84.06 Payor: Choung Ang Total Payments: $84.06 Balance Due: $0.00 Page 1 of 1