Permit 0,k Ak - ,
1111 •
° Community Development
T I L. IL D 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: ❑ Owner ❑ Applicant ❑ Contractor Et City Staff
(check one)
1
REFUND OR Name:
INVOICE TO: (Business or Individual) Ai/it
it
Mailing Address: ' v . .
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
n i. CANCEL PERMIT APPLICATION.
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).
\I 0 \
it #: l.L)12- apt 0 - 06 !O
Site Address or Parcel #: / 0 9 5 (..0 L D6- ao 1 A) 6fZ 12 -7D ,
Project Name: — /2 j y � L p
10\ 0\1°
V - Subdivision Name: Lot #:
, EXPLANATION: 4.J►b'c. F X7 j2 e.i3/3 e,J PLM®'t 16 - DO do2
Ex cc f. b i 7 Aifcw /) 5 T ! b e y s v t o Pt go /o - oo a G a.
2 -00 ?Di 90 1- 0 toIb2.Z /2E6Uu12 7D
Signature: C , Date: r/( //0
Print Name: 0 th611 W ii
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
FOR OFFICE USE ONLY .
Rte to S s Admin: Date ' IN / D Rte to B1d: Admin: Date /j ij B 1 " v
Refund Processed: Date /c/ /J- By Invoice Processed: Date By
Permit Canceled: Date /p /j //o By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPer mitAction.doc Rev 07/26/07
Accumulative Sewer Tally Parcel # 1 S135BA00100
Tenant Name: Thirsty Lion * *RL V ISI:;D ** This SWR# 2010 - 00104
Site Address: 10205 SW Washington Sq Rd This PI ,M# 2010 - 00262
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
Baptiscry /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 - Bach 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 1 4 3 12 2 8
- 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 2 10 7 35 5 25
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 I -1P) 16 0 0 0 0 0
- Commercial (to 5 1 -IP) 32 0 0 0 0 0
- Industrial (over 5 1 -IP) 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 6 12 13 26 7 14
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- 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 2 12 4 24 2 12
Urinal 6 0 3 18 3 18 0 0
Previous EDU Count 0 0
Capped EDU Credit 4.1 65.6
TOTALS 0 0 14 56 30 115 16 -6.6
Current Fixture Value -6.6 divided by 16 = -0.4 Current EDU 1 EDU = $ 4,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -6.6 divided by 16 = -0.4 over (under) $ (1,640.00)
Enter EDU Change Here -0.4
Notes: Demo credits from PLM2010 -00202 applied. 8/11/10, demo credits revised on P1.M2010- 00202, added an additional 1 EDU to 3.1 EDU credits.
Authorized Name /Signature: Debbie Adamski Date: 8/10/2010
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 \Sewer l'allySheet- 3600.xls 06/25/08