Permit CITY OF TIGARD PLUMBING PERMIT
2 COMMUNITY DEVELOPMENT Permit #: PLM2009 -00325
13125 S W Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 11/04/2009
T 1 G ARD' Parcel: 2S102CA00935
Jurisdiction: Tigard
Site address: 13410 SW VILLAGE GLENN CT
Subdivision: Lot: 0
Project: Carlisle
Project Description: Install ice maker.
Owner: FEES
CARLISLE, ANDY & KATHIE Quantity Description Date Amount
13410 SW VILLAGE GLENN CT
TIGARD, OR 97223 1 ea Ice Maker 11/04/2009 $12.51
1 12% State Surcharge - 11/04/2009 $8.70
PHONE: 503 - 684 -5954 Plumbing
60 ea Minimum Fee Adjustment - 11/04/2009 $59.99
Plumbing
Contractor:
BLUE LINE PLUMBING INC
1820 SW WYNWOOD AVE
PORTLAND, OR 97225
PHONE: 503 - 706 -0091
FAX: 503 - 644 -7373
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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: d./1` ?p / - Lr C y*/ /C N
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.
FROM : FAX NO. : Nov. 11 2009 08 { 07AM P1
• Pi ' ECEIVED
NOV 12 2009
COMM i unity Development BUILDING DIVISION
•
• " a v ate +vest for Permit Action
`1404 — .—.
TO: CITY OF TIGARID
Building Division ScrviicE:s 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) E 0 .
Mailing Address: e0 0 , .S - /U IX/014Th 19V,
City /State /Zip: 7C>���- 97� .
Phone No.: 6 3 7 CO 7
PLEASE TAIL ACTION FOR THE fFIEMO) CHECKED (✓):
CANCEL PERMIT APPLICATUir
\(' REFUND PERMIT FEES (attach receipt, if available). V'
INVOICE FOR FEES DUE (attaa;,h case fee schedule and explain below).
REMOVE CONTRACTOR FROM PEIt1VIIT (do not cancel permit).
Permit #: al/ 02 aD 9 - DQ 3 1
Site Address or Parcel #: S. l't'' /ILLI' »E 6' ,E4j,V 6/ -
Project Name e4kft
Subdivision Name: Lot #:
EXPLANATION: � '9 /vC.
Signature; Date: 1
Print Name: /KO ckOi
/ //x040
City of Tigard
T I G A R D 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: Blue Line Plumbing DATE: 12/10/09
1820 SW Wynwood Ave.
Portland, OR 97225 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 175920 Case #: PLM2009 -00325
Date: 11/04/09 Address /Parcel: 13410 SW Village Glenn Ct.
Pay Method: CreditCard Project Name: Carlisle
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
.REFUND INFORMATIONc .,; _ .� _....,....:._ .. •
Fee Description From Receipt Revenue Account NO. Refund
- :Example:... [BUILD] Permit Fee Exarnple: 0000 - 432000 $ Amount
Plumbing Permit Fee 2300000 -43101 $58.00
12% State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $510D Professional Staff O
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: „ e . By: ( "4; r ;:- ----.
Case Refund Processed: Date: 1 < ! '
I:\ Building \Refunds \RefundRequest.doc 04/13/09
•
• CITY OF TIGARD RECEIPT
n
g . _ 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
f:— -1 NL�
Receipt Number: 176275 - 12/11/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 - 00325 $ - 64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 05415C DHOWSE 12/11/2009 $ - 64.96
Payor: No Skoro, Blue Line Plumbing
Total Payments: $ - 64.96
Balance Due: $64.96
Page 1 of 1
•
CITY OF TIGARD RECEIPT
i a 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TEGAR 1)
Receipt Number: 175920 - 11/04/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 -00325 Ice Maker 2300000 -43101 $12.51
PLM2009 -00325 12% State Surcharge - Plumbing 1003100 -24001 $8.70
PLM2009 -00325 Minimum Fee Adjustment - Plumbing 2300000 -43101 $59.99
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 05415C DROWSE 11/04/2009 $81.20
Payor: No Skora, Blue Line Plumbing
Total Payments: $81.20
Balance Due: $0.00
•
Page 1 of 1
• .FROM : FAX NO. : Nov. 03 2009 01:38PM P2
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I i
.Building Fixtures et c\I , r , : : t r 5 t i i 1 1 " fi r ,x4 1 �4i.�i , ,
r,p City of'�i��lyd 0 � 9 si tea / /)1►B cry r�r<eltNo • . (- / j
,, 13125 SW WAiL Blvd, Tit'n1d, OR 47223 O 3 f/ tj` r, i i 503.639.4171 • Fax: 503,598.1960 \JUG It D at e n3y Other Penult /4n.: '
40 Inspection Li 503.639.4115 ,�1G , -
QR ,�p� itca�/dr 61 9ae Pltpe 261 Internet: www.tlgard- or-gov . F ��(( O\ v1S.�tddtZf{ad/Mctlntl - • ;u.
r• �� 1' , tearenMl letbt7atkidn
® N :w vonatnit #ieml I) on '.. -1 __ Fbr s f Lo►Aredes user checklfdtt
- ddicion/alterationTraplatcmdnt .��. — Deecn°aan ea' Tow
je
A
CI Other, New l- 2 -flunk dwdllags includes 100 R For peal utill connection
o1 . ...
(. sad 2 -fiuml ly dwelling 0 Commercial /in
^ CAThco Y oot∎ifil tc',t�f • . '. • . ant (1) bath ' 312.70 � . !G �.. Commercial/industrial ' SFR(2)bath Ill
[] Memory building C] Mult1•fhnily �.-. SFR (3) bath 300.32
Master builder --_._- Oath addhional bath/kitchen 25 -02
Othe Fare sprinkler (, q4. LL) Page 2
'34)13 XNPO1i%MA; IN LOCATION' —6t---..—: ' Site iitle
Catch basin or area drain
Job site address /3 0 a i EN 18.76
Arywall, leach ilntl or troth drain 76
Suite/bldg/ape.
City/State/ZIP: 7r i& H ®� g"'1 �2 3 __H__. 18
'rooting drain (no- h ear R,: W� Peg( 2
no.: Project name: — Mnnufacturee home utilities 50.03
Cross sheet/directions to job sited; �� _ �— Manholes . 18,76 _
Rain drain connector 18.76
'� -- Sanitary sewer (no- linear ft,, -J Page 2
._ Storm sewer (no. tinder Il.; _ Page 2
- — : Water service (no- linear ft.: _�_ J Pau 2
Subdivision: • Loth no.: , Fixture or nom
Tax map /parcel no.: ' ~�� Rackflow pniventer 31.27
... Backwater valve —
I'/E,BCI rnoNtlir�'p 12.51 —
/�, f � L , ; Af�.2 �r Clothes washer 25.03
—r '"4 Dishwacher 25,02
.— „ —. Drinking fountain 25.02
' Ejcctors/sump - 25.02 ..
Er P +awr>1 . . ::1.'. - . . 4 - . Expansionlafdr . . 12.51 . _ s d
Naa ibt.� Fixture /sewer ea
te: � f� � ��� �f ��. 4 f} � � „�._.., Floor drain/ floor 25.02 J
�� floor sink /hub 25.02
Actress: Garbs dispose) — 25.02 ..�.
City /State/ZIP: D (� - _._. Hose bib 25.02
atllara ( ) 4 7 • Q J : ( ) _ .— icc maker . _L____12,51
(3 411 !..:J.,,.:!::1, ' ,1`C TAL I' p684liOPf Interceptor /grease trap 21.02 �—
Business name: Medical 8 s (value: $, ) P� 2 __
-- -- --- Primer 12.51
Contact name: .
Ron? drain (commoroial) 12.5.1
Address; , - - � Sink/batin/Iavatory _ 2502
Clty/Strte/ZTP! Solar unite (potable water) 62.54
Phone: ( ) ` Fax; : ( ) Ttib /showm/ahawer pan _ 12.51
Frnleih — _ _.._. Urinal 25.02
�,pN'f)ti4C`CUI�' — Water closet : 25.02
_...�- Water heater 37.52
Bwdneea dame r" g' M ' . ,' `. � V 4! • • Water ti ingIDWV
Ad�1ragg: ,�� r I AVE_ .. Cthot: 15.02
d .) City/3tet � o , _ I f/� ^y Subtotal
Phcme: (51%'12. .1 at v CO 9) : (S. O It t r 1 g 7' w Minimum permit fee: 572.50 5e
Plan review (25% of permit WO
CC13 > io.: J I ;� Plumbing Lie_ ne. State s,rrnharge (l2% of pain' it fee)
Authorized signature: '' ----_. 7 fi/ , , TOTAL PERM(T PEE t r / ' �j 11......"*"- �'nt name: / rp te„ r Date: /i -1 -`JT1 nib peratit applicatio i rx •, �a porieit 1p n e obtained within l80 days
ar10r it Pan been accepted as Cpmpler.
"Fee methodology act by Tri -County Building Industry Service %ord,
INIMIdit t■TerlaigV9.4)- erni+hApp.doc 10/01/09 44 .4(na.(10/0:1JCo.t,r a,
City of Tigard, Oregon ° 13125 SW Hall Blvd. 0 Tigard, OR 97223 t f „, ji b ---.,-:-
f = r . h' Ii ,
6 ' � :' :,� r,®®
December 11, 2009 , ,' ' `� -`. ”' =.,
Blue Line Plumbing
1820 SW Wynwood Ave.
Portland, OR 97225
Re: Permit No. PLM2009 -00325
Dear Mr. Skoro:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 13410 SW Village Glenn Ct.
Project Name: Carlisle
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
-. ® Credit card "return" receipt in the amount of $64.96.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4 ): 2 5 C: A / T 7
Dianna Howse
Building Division Services Supervisor
Enc.
1: \Buildin Refunds \ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 0 Fax: 503.684.7297 0 www.tigard - or.gov 0 TTY Relay: 503.684.2772