Permit W r� CITY OF TIGARD
SEWER CONNECTION PERMIT
A s . ® : 1 , ; COMMUNITY DEVELOPMENT Permit #: SWR2010 -00042
T [ GAAD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 03/30/2010
Parcel: 2S112AA00500
Jurisdiction: Tigard
Site address: 14344 SW 72ND AVE
Subdivision: NELSON BUSINESS CENTER Lot: 0
Project: Leifs Auto Repair
Project Description: .4 EDU increase.
FEES
Owner:
WALTON CWOR NELSON 13 LLC Description Date Amount
BY TTA/EPROPERTYTAX DEPT 735, PO BOX Sewer Connection Fee 03/30/2010 $1,440.00
4900
PHONE:
Contractor:
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .4
Total $1,440.00
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 Notifi on Cente . 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 estions to OUN. by . . 503.246.6699 or 1.800.332.2344.
• Iss d By: / /4 �� Permittee Signature: ��
, _
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.
w f'z - 00.41) -4
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
11
O 46.itS
October 28, 2010 ��'`., ,`q�
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Leifs Auto Repair
14344 SW 72n Ave.
Portland, OR 97224
Re: Permit No. SWR2010 -00042
Dear Sir /Ms.:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 14344 SW 72n Ave.
Project Name: Leifs Auto Repair
Job No.: N/A
Refund: ® Check #67503 & 67558 in the amount of $1,440.00.
❑ Credit card "return" receipt in the amount of $
❑ Trust account "deposit" receipt in the amount of $
Notes: Property is on septic system as verified by dye test. Refund 100% of sewer
connection fees paid for EDU increase when oil /water separater was installed.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds \Administrat ion \LtrRefund- CancelPerrnit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 '.. www.tigard -orgov • TTY Relay: 503.684.2772
III City of Tigard
r c n 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: Leifs Auto Repair DATE: 10/20/2010
14344 SW 72n Ave.
Portland, OR 97224 REQUESTED BY: Dianna Howse
Debbie Adamski
TRANSACTION INFORMATION:
Receipt #: 177358 Case #: SWR2010 -00042
Date: 03/30/2010 Address /Parcel: 14344 SW 72nd Ave.
Pay Method: Check Project Name: Leifs Auto Repair
EXPLANATION: Property is on spetic as verified by dye test from Public Works. Refund 100% of sewer
connection fees paid for EDU increase.
IN :FORMATION:. .. - . i. ' _.' ...:..:. .
•Fee:Description From- Receipt:-' ' : Rev e nue:Account:No: 'f.: -'ERefund
',Exairiple;: Building Pe mit,Fee: .' ... . :. .. Example: 23000004:3104 t - . •$Amoiint'
Sewer Connection Fee 5000000 -25500 ,$1,4400:011 ✓
saztgce .lvs'
•
TOTAL REFUND: .11.6 ✓
APPROVALS: // WO, a0
If under $5,000 Professional Staff
If under $12,500 Division Manager , ��� /
If under $25,500 Department Manager � - / ; 'z" Z�` (rte / /Z - /f
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
:; ; ';
FOR TIDEMARK SYSTEADMINISTRATIONUS ONLY :: :: ' - r
Case Refund Processed: I Date:1 / /,%' f a? I By: I 4
I: \Building \Refunds \RefundRequest.doc x 09/01/2010
Er I City of Tigard
TIGARD 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: Leifs Auto Repair DATE: 10/20/2010
14344 SW 72 " Ave.
Portland, OR 97224 REQUESTED BY: Dianna Howse
Debbie Adamski
TRANSACTION INFORMATION:
Receipt #: 177358 Case #: SWR2010 -00042
Date: 03/30/2010 Address /Parcel: 14344 SW 72 "d Ave.
Pay Method: Check Project Name: Leifs Auto Repair
EXPLANATION: Property is on spetic as verified by dye test from Public Works. Refund 100% of sewer
connection fees paid for EDU increase.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Sewer Connection Fee 5000000 -25500 $11
V va0,er: ,-
srs2ccEiPT,
TOTAL REFUND: $1,400.00
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager
d' ,
If under $25,500 Department Manager � " -' / ��° 2l� G'
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: 1 /d /Zl /O 1 By: 1.
I: \Building \Refunds \RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
n
7111 m . 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
/2 &7u/v
Receipt Number: 180159 - 10/28/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2010 -00042 $- 1,440.00
Total: $- 1,440.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 67503 & 67558 DHOWSE 10/28/2010 $- 1,440.00
Payor: Leifs Auto Repair
Total Payments: $- 1,440.00
Balance Due: $1,440.00
•
Page 1 of 1
CITY OF TIGARD RECEIPT
4
s 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD (14 / z ^ y
Receipt Number: 177358 - 03/30/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2010 -00042 Sewer Connection Fee 5000000 -25500 $1,440.00
Total: $1,440.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 48202 DADAMSKI 03/30/2010 $1,440.00
Payor: Leifs
Total Payments: $1,440.00
Balance Due: $0.00
Page 1 of 1
11111 N.
Community Development
Request for Permit Action V
TIGARD OC,
TO: CITY OF TIGARD CO
Building Division Services Coordinator IXG �'R� �I
13125 SW Hall Blvd., Tigard, OR 97223 C Oa AS1
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - oto
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name: :4___6,4
INVOICE TO: (Business or Individual)
Mailing Address: (q544-, n 7 dt ' L-Y-- Al) E-
City /State /Zip: \O 2T Lit 1J 02- 977.95/
Phone No.: 555 - ( - 5 ? 43
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
111 CANCEL PERMIT APPLICATION.
S. 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 #: 1L_V._ gsC 10 - 006 ch
Site Address or Parcel #: 1 14 3 4g c * 7 9, 40 E-
Project Name: kt 1 r IS i2 1L'r0 ..PA ►1
Subdivision Name: Lot #:
EXPLANATION: 20p l5 O P r t C_. V t r, si t,A.D t'rH- A-
-- ID y 1'T P v P. L3.
Signature: p Date: /D// //v
Print Name: 1 E.66, C q--1-_ ,,o j4 51fo
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.
c) 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.
I'OR OFFICE USE ONLY
Rte to S s Admin: Date a of B r Rte to Bld: Admin: Date /vQIO : • 0MM
Refund Processed: Date /O 07/0 BA, _ Invoice Processed: Date B
Permit Canceled: Date %0 . //v By ', Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07