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Permit • • Accumulative Sewer Tally Parcel # 1S136DD - 03400 Tenant Name: Tigard Triangle Commons, Building 4 This SWR# 2006 - 00102 Site Address: 11740 SW 68th Pkwy This PI.M# 2006 - 00204 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 Baptistry/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 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 2 2 2 2 Eyc Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 5 10 5 10 - 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 I -IP) 16 0 0 0 0 0 - Commercial (to 5 HP) 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 0 8 16 8 16 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - 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 0 10 60 10 60 Urinal 6 0 0 2 12 2 12 Previous EDU Count 0 0 Capped EDU Credit 1 16 TOTALS 0 0 0 0 28 _ 103 28 87 Current Fixture Value 87 divided by 16 = 5.4 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 87 divided by 16 = 5.4 over (under) $ 14,040.00 Enter EDU Change Here 5.4 Notes: ** *REVISED 4/21/08 ** *Revised to add demo credit of 1 EDU from BUP2005- 00327. Authorized Name /Signature: Debbie Adamski Date: 4/21/2008 Building Division I ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges. I: \Building \Sewer Tally \ SewerTallySheet-2008.xls 06/30/07 Accumulative Sewer Tally Parcel # 1S136DD Tenant Name: TIGARD TRIANGLE COMMONS, Bldg 4 This SWRt 2006 -00102 Site Address: 11740 SW 68th Pkwy This PLM# 2006 -00204 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 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 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 2 2 2 2 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 5 10 5 10 - 3 inch 5 �0 f 0 0 0 0 - 4 inch 6 0 0 0 0 - Car Wash Drr 6 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 8 16 8 16 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - 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 0 10 60 10 60 Urinal 6 0 0 2 12 2 12 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 28 103 28 103 Current Fixture Value 103 divided by 16 = 6.4 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 103 divided by 16 = 6.4 over (under) $ 16,640.00 Enter EDU Change Here 6.4 Notes: Revised to change Bradley sink to commercial sink. Deb Authorized Name /Signature: BARBARA BUTLER /Debbie Adamski Date: 5/31/2006//6/1/06 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 \SewerTallySheet.xls 7/1/05 v a 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: Pacific NW Properties DATE: 4/21 /08 P.O. Box 2206 Beaverton, OR 97075 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2006 -2761 Case #: SWR2006 -00102 Date: 6/2/06 Address /Parcel: 11740 SW 68th Pkwy Pay Method: Check Project Name: Tigard Triangle Commons #4 EXPLANATION: Demo credit was not applied at time of permit issuance. Refund credit of (1) EDU at the rate of $2,600.00 per EDU. 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 $2,600.00 TOTAL REFUND: $2,600.00 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager - Z 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 ff�.2//Od" 1 By: 1 I: \ Building \Refunds \RefundRequest.doc 05/23/07 1 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 • al TIGARD- April 25, 2008 • Pacific NW Properties P.O. Box 2206 Beaverton, OR 97075 Re: Permit No. SWR2006 -00102 Dear Sir /Ms.: The City of Tigard has processed a refund for overpayment of permit fees on the above referenced permit for the following: Site Address: 11740 SW 68 Pkwy Project Name: Tigard Triangle Commons #4 Job No.: N/A Refund: ® Check #57043 in the amount of $2,600.00. ❑ Credit card "return" receipt in the amount of $ ❑ Trust account "deposit" receipt in the amount of $ Notes: Refund for demo credit of (1) EDU that was not applied at the time of permit issuance. If you have any questions please contact me at 503.718.2430. Sincerely, / Dianna Howse Building Division Services Coordinator Enc. I: \ Building\ Refunds \Administration \LtrRefund - Overpay.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 CITY OF TIGARD 4/14/2008 *""'' , 13125 SW Hall Blvd. 4:27:26PM Tigard. OR 97223 503.639.4171 TIGARD Receipt #: 27200600000000002761 Date: 06/02/2006 Line Items: Case No Tran Code Description Revenue Account No Amount Paid SWR2006-00 I 02 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 16,640.00 SWR2006 -00102 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 45.00 Line Item Total: $16,685.00 Payments: Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid Check PACIFIC NW PROPERTIES DER 23835 In Person 16,685.00 Payment Total: $16,685.00 clteceipt.rpi Page 1 or 1 • r • 1 11 1 111 Community Development • ECEIVED TIGARD Request for Permit Action APR 212008 TO: CITY OF TIGARD CITY OF TIGARD Building Division Services Coordinator BUILDING DIVISION 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor yls City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) 1 /1 l= / (� NoPek_r t �l Mailing Address: p P� Ox n ab(P City /State /Zip: — 73SaJe2 - rb OP g7075 Phone No.: 6o - t 5500 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ , NCEI APPLICATION. 1J REFUND RMIT FEES (attach receipt, if available). II I , • CE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: P aO (Q ' CO / QA Site Address or Parcel #: ( t 7 4 p(!,J Coet Pv,WY Project Name: �Cof}2b �✓Z,,q rJ� L� eop l N O1JS < t- t ►� Subdivision Name: 13' it Lot #: X)//t EXPLANATION: �E{-to CP\t, t T p� < <GDLJ. L 5 �O i APPu £b k 4 0 " I 2 J goo 5 - c 7 . l I ' 'o i- ti��.c rJ o G o /00n oo ' �£ .2Axi ( 1 `Gn t. _ /-r i € C AF c2 ACT o ti) • Signature: • , Date: e-// itp /OE Print Name: f PrDA i• �I 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 Sys Admin: Date q OS B - ' Rte to Bldg Admin: Date y�O f B Refund Processed: Date rea "/ B i. • Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By Receipt # d6- ?7 , Date 4A /06 Method ( / Amount $ 1: \Building \ Forms \Regl'ermitAction. oc Rev 07/26/07 Accumulative Sewer Tally Parcel # 1S 1 36DD-03400 Tenant Name: Tigard Triangle Commons, Building 4 This SWR# 2006 - 00102 ''Site Address: 11740 SW 68th Pkwy This PLM# 2006 - 00204 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 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 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 2 2 2 2 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 5 10 5 10 - 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 1 -IP) 16 0 0 0 0 0 - Commercial (to 5 HP) 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 0 8 16 8 16 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - 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 0 10 60 10 60 Urinal 6 0 0 2 12 2 12 Previous EDU Count 0 0 Capped EDU Credit 1 16 TOTALS 0 0 0 0 28 103 , 28 87 Current Fixture Value 87 divided by 16 = 5.4 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 87 divided by 16 = 5.4 over (under) $ 14,040.00 Enter EDU Change Here 5.4 Notes: ** *REVISED 4/21/08 ** *Revised to add demo credit of 1 EDU from BUP2005- 00327. Authorized Name /Signature: Debbie Adamski Date: 4/21/2008 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. l:\ Building \Sewer Tally \Sewer I'allySheet- 2008.xls 06/30/07 CITY TIGARD SEWER CONNECTION PERMIT i DEVELOPMENT SERVICES PERMIT #: SWR2006 - 00102 111 � 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 6/2/2006 PARCEL: 1 S 136DD -03400 SITE ADDRESS: 11740 SW 68TH PKWY ZONING: MUE SUBDIVISION: WEST PORTLAND HEIGHTS LOT: 008 JURISDICTION: TIG Project Description: Building 4. 6.4 EDU increase. TENANT NAME: TIGARD TRIANGLE COMMONS CWS NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 6.4 TYPE OF USE: COM NO. OF BUILDINGS: INSTALL TYPE: BUSWR IMPERV SURFACE: Owner: FEES PACIFIC NW PROPERTIES ATTN: PAUL GRAM Description Date Amount P.O. BOX 2206 BEAVERTON, OR 97075 [SWUSA] Sewer Connection Fee 6/2/2006 $16,640.00 [SWINSP] Sewer Inspection Fee 6/2/2006 $45.00 Phone: 503- 626 -3500 Total $16,685.00 Contractor: REQUIRED ITEMS AND REPORTS Contact #: 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 by: '.-� -------7 �� Permittee Signature: "' �- c7. 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. Accumulative Sewer Tally Parcel # 1S136DD- 03400 Tenant Name: TIGARD TRIANGLE COMMONS, Bldg 4 This SWRt 2006 -00102 Site Address: 11740 SW 68th Pkwy This PLM# 2006 -00204 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 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 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 2 2 2 2 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 5 10 5 10 - 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 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 8 16 8 16 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - Service 3 OA' #€ 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 0 10 60 10 60 Urinal 6 0 0 2 12 2 12 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 28 103 28 103 Current Fixture Value 103 divided by 16 = 6.4 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 103 divided by 16 = 6.4 over (under) $ 16,640.00 Enter EDU Change Here g � �4 Notes: Revised to change Bradley sink to commercial sink. Deb Authorized Name /Signature: BARBARA BUTLER/Debbie Ada k/ Date: 5/31/2006//6/1/06 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 \SewerTallySheet.xls 7/1/05