Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Permit
CITY OF TIGARD MASTER PERMIT COMMUNITY DEVELOPMENT Permit#: MST2009-00207 0 13125 SW Hall Blvd , Tigard OR 97223 503.639.4171 Date Issued: 11/04/2009 r Parcel: 2S109AB07600 Jurisdiction: Tigard Site address: 13011 SW ST JAMES LN Subdivision: Lot: 0 Project: Pistor Project Description: Finish basement. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms. 0 First: 0 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage. 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Yes Total: sf Value: $30,000.00 Rear: 5 PLUMBING Sinks: 1 Water Closets 1 Washing Mach: 1 Laundry Trays. 0 Rain Drain: 0 Catch Basins: 0 Lavatories: 1 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Other Fixtures: 1 Drains: 0 Tubs/Showers: 1 Garbage Disp: 1 Water Heaters: 0 Water Lines. 0 Bckflw Prevntr: 0 MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 1 Clothes Dryers: 1 Natural Gas Heat Pump: N Hoods. 0 Other Units: 0 Furn<100K. 0 Vents: 0 Woodstoves. 0 Gas Outlets: 1 Furn-100K. 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/ Svc or For: 0 Ea add'I 500 sf: 0 20 1-400 amp: 0 201-400 amp. 0 1st W/O Svc/Fdr: Limited Energy: 401-600 amp' 0 401-600 amp: 0 Ea add'I Br Cir 601-1000 amp. 0 601+amp-1000v: 0 1000+amp/volt 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo N HVAC N Security Alarm: N Vaccuum System: N Garage Opener N All Ecompasing: N Other: N Other Description: BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: Owner: Contractor: Required Items and Reports (Conditions) PISTOR, DAVID E FIRST CHOICE CUSTOM HOMES INC 13011 SW ST JAMES LN 13115 SW ST JAMES LN TIGARD OR 97224 TIGARD, OR 97224 PHONE: 503-709-7841 PHONE. 503-880-7132 FAX: Total Fees: $1,488.18 Lermit ed sukiject to the regulations contained in the Tigard Municip al Code, State of OR. Specialty Codes and all other applicable law All work will ance wt. 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 : Oregon equines you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR h OAR 01-0 0 YYoumay obtain a copy of the rules or direct questions to OUNC by calling 503.24 699 or 1.800.332.2344 41 / ' Permittee Signature: V_4 Mechai><ieal Permit Application , FOR OFFICE USE ONLY 1144 RCity of Tigard QCr 2 qnO O 7 Q~ PermitNo.: 13125 SW Hall Blvd., Tigard, OR 97223 20 Phone: 503.639.4171 Fax: 503.598.1960 ' yOther Permit: Inspection Line: 503.639.4175 B CITY OFTIGAR Date Ready/By: fur' El See Page 2 for Internet: www.tigard-or.gov DINGDIVISI Notified/Method: Supplemental Information TYPE OF WORK COMMERCIAL FEE* SCHEDULE - USE CHECKLIST Mechanical permit fees* are based on the value of the work ❑ New construction Addition alteration/replacement performed. Indicate the value (rounded to the nearest dollar) of all F] Demolition ❑ Other: mechanical materials, equipment, labor, overhead, and profit. CATEGORY OF CONSTRUCTION Value: $ /1- and dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist. ❑ Multi-family ❑ Master builder ❑ Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling Job site address: 3o I I S ST -XA ~t XS Air conditioning LA~) (requires site plan showing placement) 46.75 City/State/ZIP: Tl 1 C/k I', D rL I? ?-Z -Z 4- Furnace 100,000 BTU (ducts/vents) 46.75 Furnace 100,000+ BTU (ducts/vents) 54.91 Suite/bldg./apt. no.: Project name: Heat um 61.06 Cross street/directions to job site: Duct work 23.32 H dronic hot waters stem 23.32 Residential boiler (radiator or h dronic 23.32 Unit heaters (fuel-type, not electric), in-wall, in-duct, suspended, etc. 46.75 Subdivision: Lot no.: Flue/vent for an of above 23.32 Other: 23.32 Tax map/parcel no.: Other fuel appliances DESCRIPTION OF WORK Water heater 23.32 Gas fireplace ( 33.39 ~j Flue vent for water heater or gas fireplace 23.32 Lo lighter (gas) 23.32 Wood/ pellet stove 33.39 23.32 Wood fire lace/insert ROPERTY OWNER ❑ TENANT Chimney/liner/flue/vent 23.32 Other: 23.32 Name: U~ ~PS To !2 Environmental exhaust and ventilation Address: Range hood/other kitchen e ui ment 33.39 City/State/ZIP: Clothes dryer exhaust 1 33.39 3533 Single-duct exhaust (bathrooms, Phone: ( IP-1) U CI - 7 v 4- Fax: ( ) toilet compartments, utility rooms 23.32 z3.~ ❑ APPLICANT ❑ CONTACT PERSON Attic/crawls ace fans 23.32 Other: 23.32 Business name: Fuel piping Contact name: $14.15 for first four; $4.03 for each additional Furnace, etc. I'J Address: Gas heat um City/State/ZIP: Wall/sus ended/unit heater Phone: ( ) Fax:: ( ) Water heater Fireplace E-mail: Range CONTRACTOR Barbecue Business name: Clothes dryer (gas) Other: Address: 1e ST, TZ V 726 "2 S-1- MECHANICAL PERMIT FEES* City/State/ZIP: G( A(:-" Al A C QyL Subtotal , Phone: CSV („Q S~ Fax: ~3) _ S Minimum permit fee ($90.00) ,.y 7 - Z j! `M Plan review (25% of permit fee) CCB lic.: -17 Q State surcharge (12% of permit fee) ,4_ ~ /t TOTAL PERMIT FEE (2,77 Authorized signature: S This permit application expires if a permit is not obtained within 180 . 44 days after,it has been accepted as complete. Print name: W IZ I LA 5 /V P X-i Date: ' Fee methodology s~ by Tri-County Building Industry Service Board 1:1BuildingiPermits\MEC-PermitApp.doc I0101109 440.46177 (I1/02/COM/W£B) U1 T-26.-2009(MON) 10:38 BeaarrLIElectr`icT (FAX)5036781108 P.001/001 Electrical Permit Annlication V • OFFICE ON LY I once„+,t Q J~/{ lh' o1' Cigard g T 2 7 2009 +^7 Itr,ml Nn' (/(/f ~Q 7 C++tr lh / M 1.111-1 titV I (all (tied l'iµard, Ott 9, IHAn w 111 11hona 5(1.1.6,30.4171 Fax 5111 r)ho ,rv 1'nmN I'ralrl". _ ~ a in■petr,on i,inc' 91.V,19.4175 Cif OF TIGARD f IT:ur 1Ay,d,:115 !»ra Rl Orr l'egr : (fir h,tr:nlrl wwty ii uril~0. uv ! !~nlihcd Ntrih - BUILDINGDIVISIQ «1 K« rlen+n+rwlrnrnr~~ri.M a; e N. ; _ _ ../_/C~._....._ NF _ r - •1.v1% OF 1VORK 1 Y.1AV REViF v : • 1 "1'Iril • chrnk~-»Il I ha, M11111 ,uhnnt I r is nl plebs w:RUrU9 [t1K,lp47 CRlca ( ❑ Neu u3tis t.tiur ASclitianlaHcnaionfrty5tuccnlcol 1 Q "k,+h'r rn liw,ief 4041 a,npa nr n,.rre 0 Ruitd,nr u,er three M,mr,.. f711tct - ~ ,rrc I ,c asadubk li,u t r nnolhiotl FC _ CATdlt1°'OF CO~Iti'CItl1CTlOP1 140x01 Qbfun+s+andt rrtA . r,c.•e4, Irl c;cm u,np~ at 1 ..-14,W QCrmn,rrciuf•urt attru•u6ural - • 1444 nm,ly dwelling [2 ColnrncrciaL+indtlslrl:tl ©Actessan huihi.... r,nl,d JI)l 1w1u,rr i cct d s it wdu w ❑ t fuilinQ l,uiimpk kfupp jir. i L-1t,'tlllll•If1n77.1v ksicrhuildcr ~1111TCr: { CJ I16r pump Qtnr,xlLl'u,n ui'7}r.VAnr . .~Igl3 til'f7i JfM1KUltlr iAflQ V« N ~pt. -I !]limo Aun M, Irrarr srtiarMClr4rn,Cd xyy+enlr r , 'it, 11 l.t7C.1'l') ti ~ 1%04ttian o fcc* in rn:;r.xk,ndpi I;J-A" "li","t•?" "I•t" t Ir+h nn ; Jnh tiizc I,dllrcx, T th,llp<„ ulrty. «ropalwy. ~i% of mnrc rrr»knfial unn.j, ❑ Recraalkwi ,whikk Auks. Cih /tihrlcl1 11': h ?~pU s y''~ i C ( U 11"1111-LAIC hwilitiri Q SUMN valtapa kn ntu,r shun . _ ❑ 1lvmduus Ilxatianr. trUtl rolls nna,t,ul. tiuiluhkllz hrpr, no., I'nrj,~t name: 1 Ketvrre or 6rr,lrr +d),t mnr,m M' morn. t,ross ~irecl'4hrCCttnnc In joh xitc: Nr".h"~C11E~111.1f= ~ r r_.ft Neo rrnldrnti,rl x(rrt lr- nr nlstlti-runrll_r dwclllviR unit. lS~ Intittd+w:lliurhrd {luru~r. Subdivision; LATI. n,T,:. 1;04141 tiy. tl. or laws I68.St s GAO, add, 1-5GU sq, 'ft. or ~xxtintr 11.9: l 'I1tfc.rn*purcel flri.t • 4414 )Or S`'CJI't1t 'sc:.:... t rl hn.ce, nyf 77- 7--i t .i,r,iwt) cnrrRy, allil6•I'amity . rc,idontud wtol AI*,w. . 11 liJ,l9t 2 Ser•ci, eo or:i edersImstallatlun.ullernlion.nhclfartrlr!cadSrn _ c C r i7.7U Y)) sltl tt IU Sh 2 ,i) nrrgrl trr .Sin. ~l umpti y/., .rte ~,r+~ gill tTYnntt t4, r;Url nerpa ~bU,34. , _M_.._,..~...._.. 641 nmpKtn 1.1700wrips 301.f]i ddi, : C+!K ~3U 1 Z.:J „rj ~ 17jvct 1,000 allips Volt rnr tTrTr crvixrr rrr fccrlrSa• Itt~1S+l1AtJnn nitcrntiun, anll)Or 1'tdunc: 1.Sa t 1~- _ ~.•1'ae ( ) 2141 mmnw,rr Icv+t 59.3G 2Ul~tnn,vtu4gU;urs,.w - 1.S.C1fi 2 thvner 413121Jsttfo31:' i ht, n1Bt'&1111tiOn if h608 ,n4idc nn (tc0p0rty-tl18t I Uw'n Which is tint inicn4lcd Inr ~:11c, II':t_iC,.. rrtnt, or ~clTltnpc„ ntxnitilinR In (11iti M4i, •1<l9, h'~17, and 'til 1. I 4nl nrn ,a to fA'1 nrtrp,: Itill;,r~( « +r1 ++t• ax(cuwislo Cr.mne'l L')wnCrtil,AClltltr::, f3uli f lipI'icliiuhrr~rcuitx,t+thS(~ wch . ,A?Pt 7.C,1 tv 1±F`Fr-SON ahnvc scn ice tit Iccclc r lcc. " " _ rnrh hrtaTCh rireuri. 742 1~ttrirtcK> rtn(Tt~: It, Fee lilt branch cijom6 ,rirOraua scr,•icc or terdCr rcr., (;Itt1tSi711:lRfq: ( ~ l first irRlnch Cl7l"4111. 5f:.7.9 W ...T tlticlCCwS: 17-01414)111 brunch C: cuil 7,42 r.. u _ C;i(yr5fil(t•llil': Burl, Rltlrsutartutcd ar „tC+dulur 1a7.~4 - _.,.,...,..n... ,.....,,.-r.._~.- . dweflina,,scryicc rtsfcL'or rnxEcT° Phone 12rk•, ww4l r;strly +5714. 2 , L •m:tll: - Niin 1 or irfi}!ATf 1,171 tiiri C +YJ.S t t - t,1C"(:<3tt:.:;~::.:-i, 5i~s, ur Ksuttinc tiRhtiii,p; 41.544 . !"~'1 2 Signal ciro;igs) nr limited, t.iusincss nntnc: ~j~(r~ rrr~ cnc4 , tuner, nlleracion, or t•~ ls~ldress: , 1cm:ir,u. flcgcrirle; l' l.:itvl yl ,ic//IP ~rn~^~ / ~ F sr11 A+145 1ourri itilk iinn'o~arPr(larrirhte b+ ape nr6l,c abrrre 1 1..a- I ~1-L•^Lrf--- I pt r ki.opextir n Irhx>nc 1 P 1'anc Invaut,palim _ _ - .'~--J...7•? 1,,!~ O. rxT hour r t hr mia)' G623 jriduxlrint pistnt V~r how 7N kK h . . -1 IaI4MITJLJ Supry. Llcctrician signlfure, ltxluireil; j SuhSutal: 4Z x 1'r6li nzartTe:, 1'1ata, ~ ~~'Z '-~3'i 1 irl___±h, rc-.~,c•+~f'~o>r Cm,il fhc), ~4u111orJzerl 9?I+r, 4041404:. ~ ~ 7?6~7'~Y.;1.~I2kh11°P'4°l3Tx':.. Thif prr,nil Applk'Au r, nrpirt. iru' prnnit il. 11 it ei urged ,rllhhr .Rfl ry 1'1104 r1an17:: .Dx+li.; f drys v.rrrr 11'.r+A:r 1,+auACr41MY+,t 4ACr+,nphY4lr•. Nurubcr nT,+rgrparnuns nllaiveJ lrrr (r4nniL raruNWkrg+nelrul,r•,nt,P.t"rtne4ra{RV.dr,eo ,!Nill~iw aua.cnT;7/lr^rl.i-4•ixM1r~KH.cb, AP► Building Permit Application L."!" t / Residential ED Received -f ' OFFICE ONLY City of Tigard Date/ By: f O Permit No.: y SOD C ° 13125 SW Hall Blvd., Tigard, OR 9723T S 7 2009 Plan Review Phone: 503.639.4171 Fax: 503.598.196D C~ DateB : Other Permit: Inspection Line: 503.639.4175 Date ReadyBy: luris 19 See Page 2 for Internet: www.tigard-or.gov CITY OF TIGARD Notified/Method: Supplemental Information R m nING DIVISION TYPE OF WORK REQUIRED DATA: 1-AND 2-FAMILY DWELLING ❑ 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. 1-and 2-family dwelling ❑ Commercial/industrial Valuation: S 30 (Dp 0 ❑ Accessory building ❑ Multi-family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: 130\\ S S S~f1'1 ~S LA-> New dwelling area: 13S01- square feet City/State/ZIP: T\ C A/(,(J Z~. Garage/carport area: square feet Suite/bldg./apt. no.: Project name: Covered porch area: square feet Cross street/directions to job site: Deck area: square feet 13 S T Other structure area: - square feet REQUIRED DATA: COMMERCIAL-USE CHECKLIST Subdivision: Lot no.: 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. -F1?JL&yk ,`.n FNT Valuation: S Existing building area: square feet New building area: square feet ❑ PROPERTY OWNER ❑ TENANT Number of stories: Name: AU -e- I? S-Tp Type of construction: Address: 3D S I,J zT Occupancy groups: City/State/ZIP: AA Z Existing: Phone: (SG3) ~O - '784. ( Fax: ( ) New: ❑ APPLICANT ❑ CONTACT PERSON NOTICE Business name: T M T C.mo Lcy_ GUSTvwI /11 /&)L, All contractors and subcontractors are required to be Contact name: -i-~ A~ licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: 3 1is S L-1 A, VIC L W jurisdiction in which work is being performed. If the City/State/ZIP: -R applicant is exempt from licensing, the following reasons p~t~W , apply: Phone: (5~ ) V Fax:: (S63 ) g Z~L CQ 4 C E-mail DQ-W ,AM tLvltd 0 ovAtL- GOw-. CONTRACTOR Business name: fJ (Z.5"T CtLOICX- CUB O Its I &K - BUILDING PERMIT FEES* Address: Please refer to fee schedule Structural plan review fee (or deposit): City/State/ZIP: Q i30 `)L3 Fax:(_1N03) S2,1 _ FLS plan review fee (if applicable): Phone: lJ ccB lie.: 13 82 Z\ Total fees due upon application: Amount received: 0 01 Authorized signature: r~ This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: Date: p 7.Gri O * Fee methodology set by Tri-County Building Industry Service Board. 1:\Building\Permits\BUP-RES PermitApp.doc 11/6/07 440-4613T(11/02/COM/WEB) .RECEIVED Plumbing Permit Application Building Fixtures OC T 2 7 2009 FOR OFFICE USE ONLY Received q City of Tigard ITYOFTIGARD Date/By: p aZ PermitNo.: hTa30U9-DD~p n 13125 SW Hall Blvd., Tigard ~r Phone: 503.639.4171 Fax: 503.591 6b' DIVISION Plan Review Other Permit No.: Date/By: Inspection Line: 503.639.4175 Date Ready/By: J ® See Page 2 for Internet: www.tigard-or.gov Notified/Method: Supplemental Information TYPE OF WORK FEE* SCHEDULE ❑ New construction ❑ Demolition For special information use checklist. Description Qty. I Ea. Total Addition/alteration/replacement ❑ Other: New I- 2-family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 312.70 l-and 2-family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 ❑ Accessory building ❑Mu1ti-family SFR (3) bath 500.32 Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler (4 sq. ft.) Page 2 t2k + 0 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: 11 S S''~ 5A ~S L~ Catch basin or area drain 18.76 City/State/ZIP: , CA, ~qw O fl- 9L 2 r Drywell, leach line, or trench drain 18.76 t 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 ST w' G N~ pfd w Rain drain connector 18.76 Sanitary sewer (no. linear ft.: Page 2 Storm sewer (no. linear ft.: Page 2 Water service (no. linear It.: Page 2 Subdivision: Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRHyf ION OF WORK Backwater valve 12.51 Clothes washer 25.02 Zjr Q Urb. Y►'I fy,V Dishwasher H p 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 2~,Q PROPERTY OWNER ❑ TENANT Expansion tank 12.51 Name: V 'G PLL~ 2 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: 651) '709 - -78+1 Fax: ( ) Ice maker ( 12.51 , •j i ❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02 Business name: Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: Roof drain (commercial) 12.51 Address: Sink/basin/lavato - war. 25.02 City/State/ZIP: Solar units (potable water) 62.54 Phone: ( ) Fax:: ( ) Tub/shower/shower pan 12.51 E-mail: Urinal 25.02 CONTRACTOR Water closet 25.02 Water heater 'EXLgsr 1 37.52 Business name: Waterpiping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal .ZI 7:od- Phone: (5 ) &Rg --734-"'L Fax: ( ) Minimum permit fee: $72.50 CCB Lic.: ' 82.6 4(_e_ lumbing Lie. no.: S(QZ Plan review (25% of permit fee) State surcharge (12% of permit fee) -72,5. Authorized signature: TOTAL PERMIT FEE F '2 Print name: ` 'Q 2 ~~C Date: ~p Q 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. 1:\Building\PermitsTLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB) • • City of Tigard, Oregon ° 13125 SW Hall Blvd. © Tigard, OR 97223 • U1 November 6, 2009 Tim Walker 13115 SW St. James Ln. Tigard, OR 97224 Re: Permit No. MST2009 -00207 Dear Mr. Walker: The City of Tigard has processed a refund for overpayment of permit fees on the above referenced permit for the following: Site Address: 13011 SW St. James Ln. Project Name: Pistor Job No.: N/A Refund: ❑ Check # in the amount of $ ® Credit card "return" receipt in the amount of $136.53. ❑ Trust account "deposit" receipt in the amount of $ Notes: Refund 100% of fire sprinkler fees paid as they were previously collected under separate permit on PLM2009- 00316. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Coordinator Enc. I: \Building\ Refunds\ Administration \LtrRefund - Overpay.doc 01/16/07 Phone: 503.639.4171 e Fax: 503.684.7297 e www.tigard- or.gov a TTY Relay: 503.684.2772 City ®f Tigard TIGARD Aeeela Refund Request This form is used for refund requests of land use, engineering and building application fees. Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be attached to this form. Refund requests are due to Accela System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Tim Walker DATE: 11/5/09 13115 SW St. James Ln. Tigard, OR 97224 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 175905 Case #: MST2009 -00207 Date: 11/4/09 Address /Parcel: 13011 SW St. James Ln. Pay Method: CreditCard Project Name: Pistor EXPLANATION: Refund 100% of fire sprinkler fees paid as they were collected under separate permit on PLM2009- 00316. , •REFUND. INFORMATION:. : F•ee Descri tioin From: :Receipt • '. R' ,P. ,� ]p, a .eriie;Accoiint�Nb::.` Refuncl.� 'E cam' les' UILD .Perr :. p. ±�`[B. � t Fee , • ... example:,: �24'S- 0000= 432000 .. ,,, .: � $ "Ari%uiit: • , Fire Sprinkler 2300000 -43101 $121.90 12% State Surcharge 1003100 -24001 14.63 TOTAL REFUND: $136.53 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager �1 ? !� r °•.:,:., : t 1`_ _,__._.. If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board :::FOR.ACCELA SYSTEM =ADMINISTRATIONUSE:.,ONLY Refund Request Reviewed: Date: r': S ? 4f By Case Refund Processed: Date: , B ;.= ..... 1: \Building \ Refunds \RefundRequest.doc 04/13/09 Community Development J I.1 G A R D Request for Permit Action NOV (; 5 2009 CI i i Cf= E lump TO: CITY OF TIGARD BUILDING DIVISION Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) M L Clo Mailing Address: 1 Z 1 I J am' 6 Pt H 16 City /State /Zip: '1 r, dQ ci aa4 Phone No.: Db3' S$b' * 7 f 3 � PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANCEL PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: j'ir ,0o - bO2lo'7 Site Address or Parcel #: 1 - 6 n It ` - 7379Nf.S L3 Project Name: `, r (Z, Subdivision Name: r316. Lot #: 13/A- EXPLANATION: I .ctFu e pet ►J 1�1 � >:€ Af, lr u3A s Ce>1 b CA NIT? tIL N-11 A009- 0031 : c - 7,7/-; e . - / - 67 4 7 /L Signature: Date: 11 / 5 - 16 9 Print Name: Tf1, 'f. Avert Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE•ONLY' Rte to S s Admin: Date niZEIE PARKI Rte to Bld• Admin: Date / /AM= B Refund Processed: Date /1.76/e5. By . Invoice Processed: Date By Permit Canceled: Date �x.://,'"— By - 44— Parcel Tag Added: Date By Receipt # / j5 �'�; Date, // y % ;: Method (_'. /= Amount $ I: \ Building \Forms \RegPermitAction.doc !Rev 07/26/07 • CITY OF TIGARD RECEIPT i a ; 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD AEA( (Aii) Receipt Number: 175946 - 11/06/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2009 - 00207 $ 136.53 Total: $- 136.53 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 004310 DROWSE 11/06/2009 $ 136.53 Payor: Tim E Walker Total Payments: $ - 136.53 Balance Due: $136.53 IN Tidemark System Administration 1L I - / Finance Department Request Date: �/ / �v /, 2 7 To: L/ Liz Lutz Angela McCoy From: Dianna Howse / Re: Receipt #: /759o5, / ,5.9 y a Please process this request as follows: Journal Entry (route copy of JE to Dianna Howse). Reversal (fees have been reversed on Revenue Account Report). Credit Card Return (fees have been G r reversed on Revenue Account Report). Other /Explanation: X6 gu n/.\ Pr£'vi /=F F Thank you! ..,„„, _•_ __ I:\ Building \ Forms \RteSlip- FinanceReq.doc - Page 1 of 1 CITY OF TIGARD RECEIPT a p 1 . 13125 SW Hall Blvd., Tigard OR 97223 = 503.639.4171 TIGARD U / 2 / ("A L.- Receipt Number: 175905 - 11/04/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2009 -00207 Building Permit - Additions, Alterations, 2300000 -43104 • $509.05 Demolition MST2009 -00207 12% State Surcharge - Building 1003100 -24001 $61.09 MST2009 -00207 Branch Circuits wo /Purchase Service or 2200000 -43103 • $122.96 Feeder MST2009 -00207 12% State Surcharge - Electrical 1003100 -24001 $14.76 MST2009 -00207 Gas Fireplace 2300000 -43102 $33.39 MST2009 -00207 Clothes Dryer Exhaust 2300000 -43102 $33.39 MST2009 -00207 Single Duct Exhaust (Bathrooms, Toilet, 2300000 -43102 $23.32 Utility Rooms) MST2009 -00207 Fuel Piping 2300000 -43102 $14.15 MST2009 -00207 12% State Surcharge - Mechanical 1003100 -24001 $12.51 MST2009 -00207 Fire Sprinkler 2300000 -43101 $121.90 I0 MST2009 -00207 Clothes Washer 2300000 -43101 $25.02 MST2009 -00207 Ejectors /Sump 2300000 -43101 $25.02 MST2009 -00207 Garbage Disposal 2300000 -43101 $25.02 M5T2009 -00207 Ice Maker 2300000 -43101 $12.51 MST2009 -00207 Sink 2300000 -43101 $25.02 MST2009 -00207 Lavatories 2300000 -43101 ' $25.02 MST2009 -00207 Tub /Shower /Shower Pan 2300000 -43101 $12.51 MST2009 -00207 Water Closet 2300000 -43101 $25.02 MST2009 -00207 12% State Surcharge - Plumbing 1003100 -24001 $35.64 A 0 Total: $1,157.30 ` PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 004310 DADAMSKI 11/04/2009 $1,157.30 Payor: Tim E Walker Total Payments: $1,157.30 • Balance Due: $0.00 Page 1 of 1 1111 CITY OF TIGARD RECEIPT n a .. 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 175906 - 11/04/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00316 Fire Sprinkler 2300000 -43101 $121.90 PLM2009 -00316 12% State Surcharge - Plumbing 1003100 -24001 $14.63 PLM2009 -00316 Plan Review 2300000 -43109 $30.48 Total: $167.01 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 004310 DADAMSKI 11/04/2009 $167.01 Payor: Tim E Walker Total Payments: $167.01 Balance Due: $0.00 • Page 1 of 1