Permit 71Qfo8 -�' � � v .�r. c ibcL ..
'n CITY OF T1GAR SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00107
TtGnuo 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 7/7/2008
PARCEL: 2S102CC - 00500
SITE ADDRESS: 13600 SW PACIFIC HWY ZONING: C -G
SUBDIVISION: TIGARD MARKETPLACE LOT: JURISDICTION: TIG
PROJECT: H MART
Project Description: .2 EDU increase. 7/9/08, applicant altered scope of plumbing work and reduced EDU increase
from .5 to .2.
TENANT NAME: H MART
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.2
TYPE OF USE: CMS NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
13500 PACIFIC CORP FEES
BY CAP ADVISORS Description Date Amount
38345 W TEN MILE RD, STE 170
FARMINGTON HILLS, MI 48335 [SWUSA] Sewer Connection Fee 7/7/2008 $1,550.00
Phone: Total $1,550.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow 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 copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued b LL Permittee Signature: •''_®'J c
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 the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
• Accumulative Sewer Tally Parcel # 2S102CC -00500
Tenant Name: H Mart ""REVISED*" This SWR# 2008 -00107
Site Address: 13600 SW Pacific Hwy This PLM# 2008 -00287
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
4 value capped off value added added total total
count off #s count N 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
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
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
- Bradley 5 0 0 0 0 0
- Commercial 3 0 1 3 2 6 1 3
- Service 3 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 0
TOTALS 0 0 1 3 2 6 _ 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 - over (under) $ 620.00
Enter EDU Change Here 0.2
Notes: ** *REVISED * "* Originally permitted (2) sinks and (1) 2" floor sink. 7/9/08, capping (1) sink and no longer installing 2" floor sink.
Authorized Name /Signature: Debbie Adamski OP - • Date: 7/7/2008
Buil I ng 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.
1: \Building \Sewer Tally \SewerTallySheet- 3100.xls 06/19/08
n ��� �� SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT
PERMIT #: SWR2008 -00107
TIGARD; 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 7/7/2008
PARCEL: 2S 102CC - 00500
SITE ADDRESS: 13600 SW PACIFIC HWY ZONING: C -G
SUBDIVISION: TIGARD MARKETPLACE LOT: JURISDICTION: TIG
PROJECT: H MART
Project Description: .5 EDU increase.
TENANT NAME: H MART
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.5
TYPE OF USE: CMS NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
13500 PACIFIC CORP FEES
BY CAP ADVISORS Description Date Amount
38345 W TEN MILE RD, STE 170
FARMINGTON HILLS, MI 48335 [SWUSA] Sewer Connection Fee 7/7/2008 $1,550.00
Phone: Total $1,550.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow 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 copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued y: #k L " �i .' Permittee Signature: - -�
Call 503.639.4175 by 7:00 a.m. for an inspection that busines day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
City of Tigard, Oregon 0 13125 SW Hall Blvd. • Tigard, OR 97223 y "' fi r 44
I�
K _L
GARO,
August 1, 2008
Viking Construction
17700 SW Shasta Trail
Tualatin, OR 97062
Re: Permit No. SWR2008 -00107
Dear Sir /Ms.:
The City of Tigard has processed a refund for fees on the above referenced permit(s) for the
following:
Site Address: 13600 SW Pacific Hwy.
Project Name: H Mart
Job No.:
Refund: ® Check #58572 in the amount of $930.00.
❑ Credit card "return" receipt in the amount of $
n Trust account "deposit" receipt in the amount of $
Notes: Scope of work changed which reduced the EDU count from .5 to .2 for a refund of
$930.00.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/ ��
Dianna Howse
Building Division Services Coordinator
Enc.
I: \Building\ Refunds \Administ ration \LtrRefund- RefundOnly.doc 01/16/07
Phone: 503.639.4171 o Fax: 503.684.7297 o www.tigard - or.gov o TTY Relay: 503.684.2772
o /Zc?.rOO/O
City of Tigard
•
TIGARD Tidemark 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 Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Viking Construction DATE: 7/22/08
17700 SW Shasta Trail
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 2008 -2390 Case #: SWR2008 -00107
Date: 7/7/08 Address /Parcel: 13600 SW Pacific Hwy
Pay Method: Check Project Name: H -Mart
EXPLANATION: Scope of work changed which reduced the EDU count from .5 to .2. Refund difference
of $930.00.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
[SWUSA] Sewer Connection Fee 500- 0000 - 207000 $930.00
TOTAL REFUND: $930.00
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager t
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: I ?A' -2 /f%,--- 1 By: 1 4,”7
I: \ Building \Refunds\ Refund Request.doc 05/23/07
twapm, CITY OF TICARD
i' 13125 SW Hall Bled. 10:59: ,3Am
l i
�iw,; ard. OR 97223 5113.639.4171
i TvIGARDi
ig r,2sls;
Receipt #: 27200800000000002390
Date: 07/07/2008
Line Items:
Case No "Iran Code Description Revenue Account No Amount Paid
SW122008 - [SWUSA] Sewer Connection Fee 500 0000 207000 1.550.00
Line Item Total: $1.550.0O
Payments:
Method Paper User 1D Acct. /Check No. Approval No. Dow Received Amount Paid
Check VIKING CONSTRUCTION DEB 1 168 In Person 1,550.00
Payment Total: $1,550.0(
Q �
rKrrripi.rl'� 1'nec 1 u1
"taw jr‘ECEIVE
° Community Development ja 0 9 Z00
x -� Request for Permit Action ��.� TIGARD
BU9LD G �IVlSION
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: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ` 1"�
Mailing Address: I /7 f) Q O s(RJ - C _,
Cit /State /Zip: `r , CP_ q") c 6 .
Phone No.: _cj3 E8`e - T l
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CA L PERMIT APPLICATION.
EFUN ERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel pee mt). //�� Q
Permit #: 5WR- g' e0 / 7
Site Address or Parcel #: 360o SuJ CI 1,C HWY T6cArd
Project Name: H - n A •
Subdivision Name: d/if Lot #: O/'
EXPLANATION: Ji " -s =. % •� l .� •/
£ • . �� . tL 93o ° O
Si. (Ale • • 5 ,i,r; • — (pap 1 "- . fi g5O)
ature: ..■' Date: 1 q o 8
Print Name: _
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.
S`r ,,. r ,.�*. r trAI r -*r a- I'O gqF; ICE, USE "ONL'YV` 'rr Mr�,r`M angf- rdi a �°, ,�r
3�� Y•x, ,�L�3. .tr .�, �, mi a.,��r:r� ..., �_���.._ .. .. � av , �_ {5k� a�. , �..a.�k ..,..�q�x� Ma t,.�ar -.= �,,
Rte to Sys Admin: Date -7/q og B ! Rte to Bldg Admin: Date B
Refund Processed: Date 7 /2Z /o6 By ;!�•. - Invoice Processed: Date By
Permit Canceled: Date /1/fi)- By i/ * Parcel Tag Added: Date By
Receipt # Date Method Amount $
1: \ Building \ Forms \RegPermitAction.doc Rev 07/26/07