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Permit r q CITY OF TIGARD SEWER CONNECTION PERMIT o COMMUNITY DEVELOPMENT Permit SWR2009-00116 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/22/2009 Parcel: 2S112D000500 Jurisdiction: TIGARD Site address: 15875 SW 72ND AVE Subdivision: OREGON BUSINESS PARK III Lot: 40 Project: Calypte Project Description: .2 EDU increase. FEES Owner: PACIFIC REALTY ASSOCIATES Description Date Amount 15350 SW SEQUOIA PKWY #300 Sewer Connection Fee 10/22/2009 $720.00 PORTLAND, OR 97224 PHONE: 503-624-6300 Contractor: PHONE: FAX: Type of Use: COM Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: .2 Total $720.00 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with 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 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: Permittee Signature: djva~~ Call 503.639.4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on thejob site until completion of the project. Approved plans are required on the job site at the time of each inspection. Accumulative Sewer Tally Parcel # 2S112DC00500 Tenant Name: Calypte * Qtd i gP O x.- This SWR# 2009 - 00116 Site Address: 15875 SW 72nd Ave This PLM# 2009 - 00304 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value capped off value added added total total count off #s count # value #s values Baptisery/Font 4 0 0 0 0 0 Bath - Tub /Shower 4 0 0 0 0 0 - Jacuzzi /Whirlpool 4 0 0 0 0 0 Car Wash - Each Stall 6 0 0 0 0 0 - Drive through 16 0 0 0 0 0 Cuspidor /Water Aspirator 1 0 0 0 0 0 Dishwasher - Commercial 4 0 0 0 0 0 - Domestic 2 0 0 0 0 0 Drinking Fountain 1 0 0 0 0 0 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 0 0 0 - 3 inch 5 0 0 0 0 0 - 4 inch 6 0 0 0 0 0 - Car Wash Drn 6 0 0 0 0 0 Garbage Disposal - Domestic (to 3/4 HP) 16 0 0 0 0 0 - Commercial (to 5 HP) 32 0 0 0 0 0 - Industrial (over 5 HP) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 Oil Sep (Gas Station) 6 0 0 0 0 0 Rec. Vehicle Dump station 16 0 0 0 0 0 Shower - Gang (per head) 1 0 0 0 0 0 - Stall 2 0 0 0 0 0 Sink - Bar /Lavatory 2 0 0 0 0 0 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - Service 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer - Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 0 0 0 0 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 1 16 TOTALS 0 _ 0 0 0 1 3 1 -13 Current Fixture Value -13 divided by 16 = -0.8 Current EDU 1 EDU = $ 3,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change -13 divided by 16 = -0.8 over (under) $ (2,880.00) Enter EDU Change Here -0.8 Notes: ** *CREDIT'S ARE FROM PLM1999- 00192 * ** Authorized Name /Signature: Debbie Adam fi\V Date: 12/17/2009 u ding Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be , submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I: \Building \Sewer Tally \ SewerTallySheet-3600.xls 06/25/08 . Accumulative Sewer Tally Parcel # 2S1120000500 Tennant Name: Calypte This SWR# 2009 - 00116 Site Address: 15875.SW 72nd Ave This PI..M# 2009 - 00304 Fixture Value Previous Previous Credits Cappcd Fixture Future Ncw New # value capped off value added added total total count off #s count # value #s values Baptisery/Font 4 0 0 • . 0 0 0 Bath - Tub /Shower 4 0 0 0 0 0 - Jacuzzi /Whirlpool 4 0 0 0 0 0 Car Wash - Each Stall 6 0 0 0 0 0 - Drive through 16 • 0 0 .. 0 0 0 Cuspidor /Water Aspirator 1 0 0 0 0 0 Dishwasher - Commercial 4 0 0 0 0 0 - Domestic 2 0 0 0 0 0 Drinking Fountain 1 .' 0 0 0 0 0 , Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 0 0 0 -3inch 5 0 • 0 0 0 0 - 4 inch 6 0 0 0 0 0 - Car Wash Drn 6 - 0 0 0 0 0 Garbage Disposal - Domestic (to 3/4 HP) 16 0 0 0 0 0 • - Commercial (to 5 HP) 32 • 0 - 0 0 0 0 - Industrial (over 5 HP) 42 0 • • . 0 0 0 0 Ice Machine /Rcfrigrator Drain 1 0 0 • 0 0 0 • Oil Sep (Gas Station) 6 0 0 0 0 0 Rec. Vehicle Dump station 16 0 0 0 0 0 Shower - Gang (per head) 1 0 0 •' 0 0 0 - Stall 2 0 0 0 0 0 Sink - Bar /Lavatory 2 0 0 0 0 0 - Bradley • 5 0 • - . 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - Service 3 0 0 • 0 0 0 Swimming fool Filter 1 0 0 0 0 • 0 Washer - Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet- 6 0 0 0 0 0 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 1 16 TOTALS 0 0 0 _ 0 1 3 1 -13 Current Fixture Value -13 divided by 16 = -0.8 Current EDU 1 EDU = $ 3,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change -13 divided by 16 = -0.8 over . (under) $ (2,880.00) Enter EDU Change Here . -0.8.. Notes: ** *CREDITS ARE FROM PLM1999- 00192 * ** Authorized Name /Signature: Debbie Adams10 Date: .12/17/2009 . • Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I: \Building \Sewer Tally \SewerTallySheet- 3600.xis 06/25/08 A ..rtName- Pr, ar t-kkHitJ Asti �et s Accumulative Sewer Tally This SWR #: Mg 4 - G'a/ 37 .. ,dress: /5'05 5w 72, - /9L) This PLM #: Ia 4 q -coq D Fixture Value Previous # Previous Credits Capped Fixtures Fixtures New New . • Value Capped off value added # added total #s total • • Count off #s count value values • Baptistry/Font. 4 Bath - Tub /Shower 4 - Jacuz/Whpl 4 Car Wash - Each Stall 6 - Drive Through 16 Cuspidor/Water Aspirator 1 1 Dishwasher - Commer 4 1 W 1 11 - Domest 2 - Drinking Fountain - 1 , Eye Wash 1 / Floor Drain /sink - 2 inch 2 1 i I 4` - 3 inch 5' - 4 inch 6 - Car Wash Drain 6 Garbage Disposal 16 - Dom (to 3/4 HP) - Comm (to 5 HP) 3 . - Ind (over.5 HP) 48 Ice Machine /Refrigerator Drains 1 • Oil Sep (Gas Station) 6 Recreational Vehicle Dump Station 16 Shower - Gang (Per Head) 1 . - Stall 2 . Sink - Bar /Lavatory 2 3, `P . - Bradley 5 - . ' - Commercial 3 1 - 3 / 3 - Service 3 ` Swimming Pool Filter 1 , Washer. Clothes 6 Water Extractor 6 Water Closet. Toilet 6 3 1 q Urinal 6 • TOTALS A5 jp C( 3 ?.) 3 c'( c9 3 , Total fixture values: g3o1, divided by 16 = / -/.5O EDU - , ` – 7� d /` --1"- HISTORY ( (J PLM# EDU# [ (Q SWR# / ., PLM# EDU# SWR# PLM# • EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# J a�la l - City of Tigard Accela Refund Request T�PGArRDr 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: Steve Adams DATE: 1/8/2010 15806 SW Upper Boones Ferry Rd. Lake Oswego, OR 97035 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 175740 Case #: SWR2009- 00116 Date: 10/22/09 Address /Parcel: 15875 SW 72 "d Ave. Pay Method: CreditCard Project Name: Calypte EXPLANATION: Per applicant's request as existing sewer credits were applied towards fees for added plumbing fixtures. REFUNDIINFO �M " :c Nt ii ", te a w ` x' x� a VdEfN '`" Y � af�d'" _� x_� _.�_ ,� ,,._ ..� ..wv. � ._ _. Yea= �.3,��- ass_ <.e,�. �.... ��'..��5. ��'.,,s"a__�.o�.�;__�,_�� _,_ � -�:��. u,��,r�� -� te! rart ?. Fv x' F r _ r, x � t cz�ti f P c § OFeelD�e FromF,Recceipt ,, M ; � ,,'. .yRevenue Account No � �`� nx � Refund i Exazt ple '(B IL ®�] Permit�Fke ; � , ,, ; ' zExa nple f2 5 0000.,„°4 Olei tAinount ' Sewer connection fee 5000000 -25500 $720.00 • TOTAL REFUND: $720.00 APPROVALS: . If under $5000 Professional Staff �;t, ., If under $7,500 Division Manager If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board NESIWOIQMSXOOFAVOMSISNIOMIAPVANILSTMTIMRSEIPINVVVRPAZIVIIIMM Refund Request Reviewed: Date: / %' /e1 ' By: -i Case Refund Processed: Date: ` /7' /0 By:�'J` ... 1:\ Building \Refunds \RefundRequest.doc 04/13/09 II I Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www. tigard- or.gov FROM: n Owner n Applicant ❑ Contractor g City Staff (check one) REFUND OR Name: �� INVOICE TO: (Business or Individual) % M Du 2GI5 Mailing Address: / 5` s Q jp L P 2 400A_)e.`S ('ta y E7) _ Cit /Zip: 1 -.4 05-co_ teoo 02- 9 7035 Phone No.: 'J - 39 , 0 - 2 Lo 1 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): N1 CANCEL PERMIT APPLICATION. M REFUND PERMIT FEES (attach receipt, if available). INVOICE FOR FEES DUE (attach case fee schedule and explain below). n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: o? ) (2 ADO 9- oa / /l, Site Address or Parcel #: / 75 6i' 7 a~ AV 6 Project Name: CA Ly Pre- Subdivision Name: 44- Lot #: d/r/ EXPLANATION: (),.. y A-0 Pi- ? L R /LE, CQ,b, -- s &H o? c02 IQge- 60/37, -, . Signature: ai.1)61.41A-K4-11 Date: / ;)/7/6 1 Print Name: 05ii3-1 i_.- P- 4b// 1"5k( 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. sir m " FOWOEFICE USE` ONLY ' 0 Rte to S s Admin: Date � e � 1 7 0 �� Rte to Bld: Admin: Date "�� B i /— Refund Processed: Date / B ./074 . voice Processed: Date B Permit Canceled: Date / 1./ -Z B •1M Parcel Ta_• Added: Date B Recei # Date Method Amount $ 1:\ Building \Formss \RegPermitAction.doc Rev 07/26/07 . City of Tigard, Oregon O 13125 SW Hall Blvd. U Tigard, OR 97223 .:11 • • TJ January 8, 2010 Steve Adams 15806 SW Upper Boones Ferry Rd. Lake Oswego, OR 97035 Re: Permit No. SWR2009 -00116 Dear Mr. Adams: • The City of Tigard has processed a refund for fees on the above referenced permit(s) for the following: Site Address: 15875 SW 72n Ave. Project Name: Calypte Job No.: N/A Refund: ❑ Check # in the amount of $ ® Credit card "return" receipt in the amount of $720.00. ❑ Trust account "deposit" receipt in the amount of $ Notes: Existing sewer credits applied to sewer permit fees. Refund 100% of fees paid. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I: \Building \Refunds\ Administration \LtrRefund- RefundOnly.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 , • www.tigard- or.gov • TTY Relay: 503.684.2772 1 City of Tigard TIGARD Accela 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: Steve Adams DATE: 1/8/2010 15806 SW Upper Boones Ferry Rd. Lake Oswego, OR 97035 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 175740 Case #: SWR2009 -00116 Date: 10/22/09 Address /Parcel: 15875 SW 72nd Ave. Pay Method: CreditCard Project Name: Calypte EXPLANATION: Per applicant's request as existing sewer credits were applied towards fees for added plumbing fixtures. REFUND INFORMATION: • . Fee Description. From'Receipt Revenue Account No. Refund Example:. [BUILD] Permit Fee : . • ' ' Example: 245 - 0000- 432000 • • $ Amount . Sewer connection fee 5000000 -25500 $720.00 TOTAL REFUND: $720.00 APPROVALS: If under $5000 Professional Staff If under $7,500 Division Manager If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board • FOR ACCELA SYSTEM ADMINISTRATION USE ONLY • • Refund Request Reviewed: Date: //d' /0 By: . Case Refund Processed: Date: / „/// By: I: \ Building \Refunds \Re fundRequest.doc 04/13/09 CITY OF TIGARD RECEIPT n 1 C . 1 3125 SW HaII Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 176516 -. 01/08/2010 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID SWR2009 -00116 $- 720.00 Total: $- 720.00 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 612263 DHOWSE 01/08/2010 $- 720.00 • Payor: Steve Adams Total Payments: $- 720.00 • Balance Due: $720.00 Page 1 of 1 • CITY OF TIGARD RECEIPT I . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TfGAR 6/` l6 //M t 1 -- Receipt Number: 175740 - 10/22/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID SWR2009 -00116 Sewer Connection Fee 5000000 -25500 $720.00 Total: $720.00 • PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 612263 LSELLERS 10/22/2009 $720.00 Payor: Steve Adams Total Payments: $720.00 Balance Due: $0.00 • Page 1 of 1