Permit CITY OF TIGARD PLUMBING PERMIT
` a COMMUNITY DEVELOPMENT Permit #: PLM2010 -00082
7IGf\RL� 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 03/19/2010
Parcel: 2S104ACO2700
Jurisdiction: Tigard
Site address: 12550 SW 134TH AVE
Subdivision: MORNING HILL NO. 8 Lot: 171
Project: Wilde
Project Description: Install (1) w/c and (1) lay.
Owner: FEES
WILDE, ERIN DANIELLE Quantity Description Date Amount
12550 SW 134TH
TIGARD, OR 97223 1 ea Clothes Washer 03/19/2010 $25.02
PHONE: 1 ea Lavatories 03/19/2010 $25.02
1 ea Water Closet 03/19/2010 $25.02
1 12% State Surcharge - 03/19/2010 $9.01
Contractor: Plumbing
OWNER
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $84.07
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: .
X ��� -ate) /4 1 e A
CaII 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.
Plumbing Permit Application l ' f 7 , 1 1 rl.
g N Il 11, TO ,''ra,'S tV 4� • ¢ !R1fi ,y•p,, i ^ '� "� , r 1�F 1 u i, rym
Building Fixtures ti' i ; , y , " " , ,, O R'OI 1 I(1' ,,liS Oi\11�
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CI of Tigard MAR R eceived
Permit No.:
114
n 131 SW Hall Blvd., Tigard, OR 97223 Date/By:
Yh2,00 'G�
Plan Review
0 Phone: 503.639.4171 Fax: 503.598h96‘0/Ps � � ® Other Permit No.:
Date/By:
' i -1 t_in It l�, Inspection Line: 503.639.4175 FbU .DaTA!G DIVISION
Date Ready/By: Juris: H1 See Page 2 tor
- , Internet: www.tigard - or.gov Notified/Method: Supplemental Information
TYPE OF WORK !FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. 1 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 ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi- family
Each additional bath/kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION .. - Site utilities:
'" / ' Catch basin or area drain 18.76
CJol:siteaddtess: ( (�9�]�l ,L� G �
City /State /ZIP: �' l L�� / 6)72_2-3 ! Drywell, leach line, or trench drain 18.76
L� ` _ Footing drain (no. linear ft.: ) Page 2
Suite/bldg. /apt. no.:13/ /4. I Project name: � t Manufactured home utilities 50.03
Cross street/directions o job site: / • Manholes 18.76
TY1V1 slit Y l C,{ J ) I ( (/ / } Rain drain connector 18.76
v /'t 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
1) DESCRIPTION 4OE, WORK r Backwater valve 12.51
----� _� W �.:. 1 3
^ Q 1 /� /� 1 L 7 Y- - ( Ciothes'washer� 25.02
IS y 1,�\I L %1 -- Dishwasher 25.02
Drinking fountain 25.02
Ejectors /sump 25.02
C❑ EROPERt OWYI ER / ❑ TENANT- Expansion tank 12.51
Name: 6p / 4 L) ',elk , Fixture /sewer cap 25.02
7 t _ l/ `� Floor drain/floor sink/hub 25.02
Address: �) 4 • l / ,
�� `'� Garbage disposal 25.02
City /State /ZIP: T7 C 72 /) 2' -- f 7z:2- Hose bib 25.02
Phone: (j)) - Fax: ( 17 ! 7 9 2.- Ice maker 12.51
• ❑ 'APPLICANT ', .❑ `CONTACT PERSON .. Interceptor /grease trap 25.02
Business name: Medical gas (value: $ ) Page 2
Primer 12.51
Contact name: 52 Q �b3 V Roof drain (commercial) 12.51
Address: Sink /basirl/lavato .rya 25.02
City /State /ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51
E -mail: Urinal 25.02
. NVatei clo`set3 25.02
CONTRACTOR - .
Water heater 37.52
Business name: Water piping/DWV 56.29
Address:
OW /1 , \ Y ^ \ (J ,� Other: 25.02
City /State /ZIP: w Subtotal
Phone: ( ) Fax: ( ) Minimum permit fee: $72.50
Plan review (25% of permit fee)
CCB Lic.: Plumbing Lic. no.:
State surcharge (12% of permit fee)
CAuthdriied`signature) TOTAL PERMIT FEE 4 3 t+ n 7
Print name: Date: 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- PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site.Utilities Qty. Fee (ea) Total Square Footage: Permit Fee:
Footing drain - 1' 100' 50.03 0 to 2,000 $121.90
Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer - 1st 100' 62.54 7,201 and greater $327.54
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 Medical Gas Systems:
Water Service - each additional 100' 37.52
Valuation: Permit Fee:
Storm &Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
Other Ins eetions or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to
P and including $10,000.00.
Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $ 1.54 for
which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to
(minimum charge - 1/2 hour) and including $25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to
Reinspection Fees 90.00/hr and including $50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for
(minimum charge - 1/2 hour) each additional $100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing Installations
please indicate work performed by fixture. Failure to Plan review is required for any of the following.
accurately report fixtures could result in increased; :sewer fees * . Please check all that apply.
Quantity by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and
Fixture Type: Replace greater, except systems designed and stamped by licensed
Previous Capped Added .Existing engineer.
Baptistry/Font ❑ New exterior plumbing site utilities for any complex structure
Bath - Tub /Shower as defined in OAR918- 780 - 0040_;
- Jacuzzi/Whirlpool
Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities.
Drive tall ❑ Any multipurpose fire sprinkler system.
Cuspidor/Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040.
Dishwasher - Commercial
Domestic Submit 2 sets of plans with any of the above.
Drinking Fountain
Eye Wash .. Isometric or Riser Diagram
Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings
that meet the qualifications above.
- 4"
Car Wash Drain
Garbage - Domestic
Disposal - Commercial
- Industrial Comments regarding fixture work:
Ice Mach. /Refrig. Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang
-Stall
Sink - Bar/Lavatory
- Bradley
- Commercial *Note: If the fixture work under this permit results in an
- Service increase of sewer EDUs, a sewer permit will be issued and
Swimming Pool Filter fees assessed for the sewer increase must be paid before the
Washer - Clothes
Water Extractor plumbing permit can be issued.
Water Closet - Toilet
Urinal .
Other Fixtures:
I: \Building \Permits \PLMF - PermitApp.doc 2
III CITY OF TIGARD RECEIPT
II
• : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
02 /C ,,�
Receipt Number: 177276 - 03/19/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00082 Clothes Washer 2300000 -43101 $25.02
PLM2010 -00082 Lavatories 2300000 -43101 $25.02
PLM2010 -00082 Water Closet 2300000 -43101 $25.02
PLM2010 - 00082 12% State Surcharge - Plumbing 1003100 - 24001 $9.01
Total: $84.07
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 619154 LSELLERS 03/19/2010 $84.07
Payor: Erin Wilde
Total Payments: $84.07
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
q
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 180967 - 01/05/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010-00082 $ -67.26
• Total: $47.26
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 619154 DHOWSE 01/05/2011 $ -67.26
Payor. Erin Wilde
Total Payments: $ -67.26
Balance Due: $67.26
Tidemark
System Administration
Finance De artment Re uest
Date: /
To: _ Liz Lutz
Angela McCoy
From: Dianna Howse/
Re: Receipt #: / `7
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
reversed on Revenue Account Report).
Other /E lanation:
/A/GA/Lg`v,e -
Thank you.
I \B \Forms \RteSlip FinanaReq.doc
Page 1 of 1
-PIM Flo d Oa
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
't
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January 5, 2011
Erin Wilde
12550 SW 134 Ave.
Tigard, OR 97223
Re: Permit No. PLM2010 -00082
Dear Erin Wilde:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12550 SW 134 Ave.
Project Name: Wilde
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $67.26.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request and project was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
r- 7
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \LtrRefund- CancelPemvtdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard - or.gov • TTY Relay: 503.684.2772
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City of Tigard
0
TI G A R D Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Erin Wilde DATE: 12/28/2010
12550 SW 134 Ave.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 177276 Case #: PLM2010 -00082
Date: 03/19/2010 Address /Parcel: 12550 SW 134th Ave.
Pay Method: CreditCard Project Name: Wilde
EXPLANATION: Per applicant's request due to lack of funds to complete project.
REFUND INFORMATION: ,. ,
Fee Descnp(t1* n From :Receipt ; Revenue Account No Refund
• Exampled' `Buil'ding °Permit °Fee '1
Exampl 230000 04 $-Amount
Plumb Permit Fee 2300000 -43101 $60.05
12% State Surcharge 1003100 -24001 7.21
TOTAL REFUND: $67.26
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager L I.
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
.FOR TIDEMARK SYSTEM MINISTRATION USE ONLY
Case Refund Processed: I Date: I /7..'" By -'
I: \Building \Refunds \RefundRequest.doc x 09/01/2010
• 11/30/2010 14:49 5035901960 CITY OF TIGARD PAGE 02/02
. RECI1 1 1. 1 ".19 )
4 Community Development DEC 8 2010
quest for %n it Action
CITY OF TIGARD
TO: CITY OF :. , a -
c�Rn
Building OR �,�
Phone: 503.7181430 Fay 503.5981960 wwv
FROM: �
( one) Applicant [] Conttactor 0 City Staff
REFUND OR Name:
INVOICE TO: W 'IA) In i
s Adder: 7I 4
/s/z: I.. 4V, - s
Phone No.: as = it 40 SE TAKE ACTION FOR THE ITEM(S) _ °��
PLEASE
CANCEL PERMIT APPLICATION. •
REFUND PERMIT FEES (attach Vii, dawdle*. �' 11314 rtworcE
FOR FEES DUE (attach cue � o
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