Permit CITY OF TIGARD PLUMBING PERMIT
.'.. COMMUNITY DEVELOPMENT Permit #: PLM2010 -00255
T I CA R �! 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/05/2010
. Parcel: 2S112AC01800
Jurisdiction: TIGARD
Site address: 15055 SW 72ND AVE
Subdivision: FANNO CREEK ACRE TRACTS Lot: 46
Project: PACIFIC PRIDE
Project Description: Backflow for irrigation.
Owner: FEES
PETROCARD SYSTEMS INC Quantity Description Date Amount
730 CENTRAL AVENUE SOUTH
KENT, WA 98032 1 ea Backflow Preventer 08/05/2010 $31.27
PHONE: 1 12% State Surcharge - 08/05/2010 $8.70
Plumbing
41 ea Minimum Fee Adjustment - 08/05/2010 $41.23
Contractor: Plumbing
D & F PLUMBING
4636 N ALBINA AVE
PORTLAND, OR 97217
PHONE: 503 - 282 -0993
FAX: 503 - 288 -0604
Type of Use: COM
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:
.40%Por r r
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.
Aug 03 10 04:09p D & F PLUMBING 503- 288 -0604 p.1
Plumbing Permit Applicat' u � , .
Building Fixtures �� �" ` ' .'' F R OFFICE E
o o c USE ONLY,'
a 13125 SW Hall City of Tigard AUG 2
Blvd. Tigard, OR 97223 Received ,� �y! -
2010 Received 3/71, 67-1-- Permit No.: p) M1Sr lo._ UC-D�
IN
Y Phone: 503.639.417! Fax: 503.5 I - -'t f'' Or Plan Review Other Permit No.: vV
i ;,� ; t� DateBv
- ' Inspection Line: 503.639.4175 t ' `
TI GARq; Date Ready /By: t a t Dl'JiSIOI` luris:
Internet www.tigard -or.gov B t1 Notified /Method: Supplemental Information
0 See Page 2 for
TYPE OF WORK .FEE* SCHEDULE
❑ New construction ❑ Demolition For special information use checklist
Description 1 Qty. 1 Ea. Total
C i Addition /alteration/replacetnent ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION _ SFR (1) bath 312.70
01- and 2- family dwelling ❑ Commercial/industrial SFR (2) bash 437.78
❑ Accessory building ❑ Multi- family SFR (3) bath 500.32
I Each additional bath /kitchen 25.02
❑ Master builder ❑Other Fire sprinkler ( sq. ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: /4 O .mil 7 Catch basin or area drain 18.76
Drywelt, leach line, or trench drain 18.76
City!StatelZlP:
Ti��1/) OJ 9 72 3 Footin drain (no. linear ft.: ) Page 2
SuitelbldgJapt. no.: 1 Project name: 1 04-e_, 04-� /02i .2G Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft.: ) Page 2
Water service (no. linear ft.: Page 2
Subdivision: Lot no,: Fixture or item:
Tax map /parcel no.: Backflow preventer J 31.27
1
DESCRIPTION OF . WORK Backwater valve 12.51
/3�- �_ �-P /re � Dishwasher washer 25.02
Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
• ❑ PROPERTY OWNER I . ❑ TENANT Expansion tank 12.51
Name: Fixture! sewer cap 25.02
Floor drain /floor sink/hub 25.02
Address: Garbage disposal 25.02
City/StateiZIP: Hose bib 25.02
Phone: ( ) Fax: ( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PE • ON 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/lavatory 25.02
City /State/ZIP: Solar units (potable water) 62.54
Phone: ( ) Fax:: ( ) Tublshower /shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
CONTRACTOR
/ Water heater 37.52
Business name: I / ( 1 " � fria 46-- Water piping/DWV 56.29
Address: . , - , ' / ,i„ 4 ,, e- Other. 25.02
City /StatelZlP: /90 - y/p q77-17 Subtotal
Phone: (y7/3 2_8"2,..-0 , pt3 Fax: (,; j) 2,e =ae de/ Minimum permit fee: $72.50 7,2,s V
Plan review (25% of permit fee) ---
CCB Lic.: 96 Plumbing Lic. no.: 2!0 3 0 State surcharge (12% of permit fee) r3
Authorized signature: f ) - (.,..., , / 1 I TOTAL PERMIT FEE 2
This permit application expires if a permit is not obtained within 180 du : s
Print name:A ,,, � Date: S' �� after it has been accepted as complete.
- % "Fee methodology set by Tri- County Building Industry Service Board
1: 41uilding ,PermirsMLMU- PPermaApp,doc 10/01/09 410- 4616TI 0,102/COM/WEB)
ffil I City of Tigard
T[GARD 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: D & F Plumbing Co. DATE: 10/22/2010
4636 N. Albina Ave.
Portland, OR 97217 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 178955 Case #: PLM2010 -00255
Date: 08/05/2010 Address /Parcel: 15055 SW 72nd Ave.
Pay Method: CreditCard Project Name: Pacific Pride
EXPLANATION: Per applicant's request as backflow did not require replacement. Refund 80% of permit
fees.
REFUND INFORMATION: Refund
Fee Description From Receipt Revenue Account No.
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Plumbing Permit Fee 2300000 -43101 $58.00
12% State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager / /
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
• FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
l Case Refund Processed: I Date: /c /i. `ilj 0 I By: 1 4' 0 J
1: \Building \Refunds \RefundRequest.doc x 09/01/2010
Aug 13 10 10:04a D & F PLUMBING 503- 288 -0604 p.1
/fffjj�rVVVV i i L
; ' t{ L
• . Community Development
AUG 3 2010
TIGARD Request for Permit Action
n , OF - ni3A
bUiLDIi a7. �F'JISIO�a
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 waw. tigard- or.gov
FROM: ❑ Owner ❑ Applicant K1 Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Bu'm' (r individual) p47:— 0 c).
Mailing Address: 1 f 6, 3 ti/. A!,../.3 / r1 L/c
City /State /Zip: ✓. c "7/ 9' 72 / 7
Phone No.: (;; 2 03
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
E 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 #: PL-/V) 1 Z01 D° DO 2— 5
Site Address or Parcel #: /5 3" S 72,14 /tie°
Project Name: d+ r ; // /` - ru!- / 06
Subdivision Name: Lot #:
EXPLANATION: 1 , 1-t - , e r ' 4 ' r - ✓ )1,6 449i / / 1/4 1 AV P/4411/ /15
•
P2_45795E C4 / , ,v,) /; ,=J,//), 774'vk 72 J
Signature: ✓'�. /56)6))-7 Date: -1 - /C)
Print Name: � �'v Olt) 74
Refund Polic
1. The Director or Building Official may authorize the refund of
a) any foe which was erroneously paid or collected.
b) not more than 81)% of the ]and use application fee when an applicaion is withdrawn or canceled before any review effort has been expended.
c) not more than HIM of the land use application fee for issued permits.
d) not more than leti. of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than till' o of the building permit fee :or issued permits prior to any inspeccon requeste.
2. Refunds will be returned to the original Payer in the same method in which payment was received Please a:low 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY •
Rte to Sys Admin: Date 78,'13111 ►J Rte to Bid: Adrnin: Date p /MAN By '7
Refund Processed: Date , -AM B d/ is Invoice Processed: Date By
Permit Canceled: Date , 2-4 , B s;ff,A Parcel Ta, Added: Date B
Receipt # 2,-.95 Date , /3 /0 Method e .P' Amount $ �/ /, Zd
]:\ Building \Form+ \R R w 07/26/07
lig n CITY OF TIGARD RECEIPT
:. 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
ALA6
Receipt Number: 180216 - 10/29/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00255 $-64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 065696 DHOWSE 10/29/2010 $ -64.96
Payor: D & F Plumbing
Total Payments: $ -64.96
Balance Due: $64.96
Page 1 of 1
11111 CITY OF TIGARD RECEIPT
U
i . 13 125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 178955 - 08/05/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00255 Backflow Preventer 2300000 -43101 $31.27
PLM2010 -00255 12% State Surcharge - Plumbing 1003100 -24001 $8.70
PLM2010 -00255 Minimum Fee Adjustment - Plumbing 2300000 - 43101 $41.23
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 065696 BTAGGART 08/05/2010 $81.20
Payor: D & F Plumbing
Total Payments: $81.20
•
• Balance Due: $0.00
•
Page 1 of 1
/ Ow! A/c) -66 • S'_
City of Tigard, Oregon • 13125 SW Hal l Blvd. • Tigard, OR 97223
Ili 1
October 29, 2010 ! ___ -,._ -_
D & F Plumbing Co.
4636 N. Albina Ave.
Portland, OR 97217
Attn: Randy Moya
Re: Permit No. PLM2010 -00255
Dear Mr. Moya:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 15055 SW 72 " Ave.
Project Name: Pacific Pride
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 backflow did not require replacement; refund 80% of
permit fees.
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- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 . • www.tigard- or.gov • TTY Relay: 503.684.2772