Permit CITY OF TIGARD PLUMBING PERMIT
° COMMUNITY DEVELOPMENT Permit #: PLM2010 -00268
T [ GARB. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/17/2010
Parcel: 2S10109100
Jurisdiction: Tigard
Site address: 12447 SW 69TH AVE
Subdivision: WEST PORTLAND HEIGHTS Lot: 30
Project: HSBC
Project Description: Replacing (12) existing urinals.
Owner: FEES
TIGARD CORPORATE CENTER Quantity Description Date Amount
LIMITED PARTNERSHIP, 15325 SW
BEAVERTON CREEK CT 12 ea Urinal 08/17/2010 $300.24
PHONE: 1 12% State Surcharge - 08/17/2010 $36.03
Plumbing
Contractor:
MCKINSTRY COMPANY
12021 NE AIRPORT WAY SUITE G
PORTLAND, OR 97220
PHONE: 503 - 331 -2461
FAX: 503- 331 -6906
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Stories:
Total $336.27
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 ...
•
Issued By: A / Permittee Signature: '
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.
08/12/2010 08:09 5033316907 MCKINSTRY PAGE 02/04
Plumbing Permit Application
Building Fixtures , i ' I rnr rirrlrr: 11tir; (.) \l.l
City of Tigard R
Il * 13125 SW Hall Blvd.. Tigard, OR 97223 AUG 1 2 2010 bate /B rernlirNo.: V ,[ y v - ... ;
Phone: 503.639.4171 Fax: 503.598.1960 Plan Revie
petc/By
C Other Permit No.:
Inspection n Lin _
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.3.639.417
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0 New construction e " "!i1'�' i:i.,
❑ Demolition Fo s /r e CJrr! information use checklist
El Addition/alteration/replacement F es. Tura
4'!1 ' " ' :/ : ' Y dwellings ( cludes ft, for each utility connection)
, ,,,;f' ,.1 I . ,, ! ,;r .. y,{�'y „ 1 :, �:�: ,; . New l
•,,... ;9ili i.: :.. ':' :,:'':' i l;'9 ! ;:,i;Ij � m e C1,W n �iIJRCL I 1 .•.;!,'' .;;i:,�,;`' :irli. ;C,.:� SFR 112�n1111
,.. i t . , ,I, ,.r, I„ ..:.::...... ..... �' ... � , 'a.,.,, f )bath 1�.7
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in 100
❑ 1- and 2- family dwelling ® Commercial /industrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi - family SIR (3) bath 500.32
El Master builder Each additional bath /kitchen 25.02
i�j� t: i }I l ,i, , ; (ilti ?' ';j !t. y gG „ , :.;'4 :;'::i.
,�y ,�,I��;�,, � ,,y � y Fire sprinkler (
j r ., i � ., ,t 1, r, .. Iii? � 441§ � i Hi'; site utrlities
Job site address: 12447 SW 69 Avenue Catch basin or area drain 18,76
City /State/ZIP: Portland, Oregon 97223 Drywell, leach line, or trench drain 18.76
Footing drain (no. linear ft.: _) Page 2
Suite/bldg. /apt. no.: J Project name: 'BBC Urinal Upgrades 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.: 09100 Fixture or Item:
Tax map/parcel no.: 25101 AA Backflow prcvcnter 31.27
Ilr, '
n.;hi�! iO11 M',4.: T.:; ::; �i�F�� "�i . !I _ - r'r r i; "' .) i H .1,: Backwater' valve 1231
,
Replace (1.2) urinate with (12) i D
2) new low flow model urinals. s washer
25.02
Dshhwasher 25.02 _
- Drinking fountain 25.02
McKlnstry Job #9388 Ejectors/sump 25-02
i' ��f,�i'il {'�I; {;1`:4 i a !� Ki� ?`ii�'111!ii�Y :'dt,i�i3'�i!'I;i .,i i3CI',i.::': �'1 ST :vision tattle
u.e lu ,u ,,, ,. 6 U I I Ii �, I . ,.1:, . e t )NLI ,` ' p I2, 51
Name: i~TSBC Fixturclsewercap 25.02
Address:
Floor drain/floor sink/hub 25.02
City/State /ZTP: Garbage disposal 25.02
Hose bib 25,02
Phone: ( ) Fax ( Ice maker
. ,: Ii !I!';;j' ji !'
.r;,n l {� I �'dtll l('I,I�ili� li;'1 :i,,1!h �,,1!!.i:!; .,.; ..i . ;;ji1 i 1 tcrc
1 { ,, �� } k 12 51
:�
1,. , 1; I (,,�i) ,(, i .,,,1.1 �.!I'Vi�h'C� � CptoC /grease trap 25.02
Business name: McKInstry Company, LLC Medical gas (value: S ) Pagc2
--- Primer 12.51
Contact name : Diane Parke, Project Coordinator _
Roof drain (commercial) 12.51
Address: 16790 N -]E. Mason Street. Suite 100 Sink/basin/lavatory , 25.02
City /State/ZTP: Portland, Oregon 97230 Solar units (potable water) - 62.54
Phone: (503) 331.2465 Fax: 331.6907 Tub /shower /shower pan 12.51
E -mail: diancp @mckinstry.com Urina 12 25.02 300.24
,
fii i: :, pol : ?I /t . t . ` ; ;k:.l( . p ∎ ; y' c.: . , .:,.,:. Wate closet
t ��, ,,,;;....:!'.• !ia; °( i , l ' ,, : , p{I�G ' 1;.'. , i.�'. .: c 25.02
'� :, I I# 1 �! , !Elll : ,� , lil. 1 ;
fl,t.J! , ,,,... � , � ; ' : . f .. � . 1, � ,.,. . , ' - - • Water heater 37.52
Business name: Same as applicant water in pWy
-° pip g/ 56.29
Address: Other. 25.02
City /State /ZIP: Subtotal 300.24
Phone; ( ) Ani ( ) _ Minimum permit fee: 4172,50
CCB i ic.: 1728] 1 � ax: P1 gyb L nu.: 37 -22PB _Plan review (25% of permit fee) n/a
State surcharge (12% of permit fee) 36.03 .7 Authorized signatu c . 6 0 �' TOTAL PERMIT FEE 336.27
Print name: Diane ' Date: 8/11 /10 1 Th/N permit application expires if a permit ix nor obtained within 180 days
,.. J after ir has been accepted as complete,
'Fee methodology set by Tri- County Building Industry Sewicc Board.
I:1lending1PO,nie\PLMU•PennhhAO .do 10/01/09 44ry4616T(10/02/C0M/WPB)
`- - U .6/k \J OK)
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 fiction 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: McKinstry Company, LLC DATE: 11/23/2010
16790 NE Mason St., Ste. 100
Portland, OR 97230 REQUESTED BY: Dianna Howse
Attn: Diane Parke
TRANSACTION INFORMATION:
Receipt #: 179092 Case #: PLM2010 -00268
Date: 8/17/2010 Address /Parcel: 12447 SW 69th Ave.
Pay Method: CreditCard Project Name: HSBC
EXPLANATION: Per applicant's request as scope of work changed. Refund 80% of permit fees.
REFUND INFORMATION: - .
Fee Description From Receipt Revenue. Account No. • Refund
Example: Building Permit Fee Example: 2300000 -43104 - $ Amount
Plumbing Permit 2300000 -43101 $240.19
12% State Surcharge 1003100 -24001 28.82
TOTAL REFUND: $269.01
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 . .
Case Refund Processed: I Date: 4r7/ /O I By: I I
0 • a -5
7,a. f
I: \liuildu \Rcfund.< \RctimdR„ 1 ucst.doc x 09/01 /2010
CITY OF TIGARD RECEIPT
q
13125 SW Hall Blvd., Tigard OR 97223
503.839.4171
T[GARD
Receipt Number: 180624 - 12/07/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010-00268 $- 269.01
Total: $- 269.01
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 037792 DHOWSE 12/07/2010 $- 269.01
Payor: Laura Scavone, McKinstry Company
Total Payments: $- 269.01
Balance Due: $269.01
Page 1 of 1
CITY OF TIGARD RECEIPT
: n
E C 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 179092 - 08/17/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00268 Urinal 2300000 -43101 $300.24
PLM2010 -00268 12% State Surcharge - Plumbing 1003100 -24001 $36.03
Total: $336.27
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 037792 BTAGGART 08/17/2010 $336.27
Payor: Laura Scavone / McKinstry Company
Total Payments: $336.27
Balance Due: $0.00
Page 1 of 1
11/03/2010 12:53 5033316907 MCKINSTRY PAGE 01/04
CE1VD Communi tY Develo A menRE •
T c ;\ �; n Request for Permit Action NOV 3 2010
TO: CITY OF TIGARD BUILDING DIVISION
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 LEI Applicant
(check one) Pp ❑ Contractor Cl City Staff
REFUND OR Name: McKinstry Company, LLC
INVOICE TO: (Business or Individual)
Mailing Address: 16790 N.E. Mason Street, Suite 100
City /State /Zip: Portland, OR. 97230
Phone No.: Diane Parke, 503.331.2465
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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).
Pe:trnit #: PLM2010 -00268
Site Addtess or Parcel #: 25101AA09100
Project Name: HSBC Urinal Replacements
•
Subdivision Name: Lot #:
EXPLANATION: Customer ed sco . e of work from installing (12) new urinals to
onl • r - .lacin . the ' • . of the existin: als.
AraMir.
Signature: c' / Date: 10/7/10
•
Print Name: a Parke
Rc nid Ps>ti�r
1. The Director or Building Official may authorise the refund of;
a) any fcc 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 expratded.
c) not more than ROM of the land use application fee for issued permit:,
d) not more than 80% of the building plan review fee when an application it canceled before any plan review effort has been expended.
c) nm more than 80% of the building permit fee for issued permit; prior to any inspeetinn 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 proceaeing refunds.
FOR O1.PJCE USE ONLY
Rte to S Admin: Date 13 Rte to Bld • Admin: Date �..- ..
Refund Processed Date i"i4® r" � m
Pennir Canceled: Date 1 �� � Ia Parcel Processed: Date ��
.` ,a PParcel Ta Added: Date Q1111111•11
1122221130UMF Date =J/�ng Method L
1: \Building \Forms\ RegpermitAerion.do R 07/26/07 Amount
PITh '' 00 2 - 6 ?-
City of Tigard, Oregon ® 13125 SW Hall Blvd. ® Tigard, OR 97223
, g el
zogroAvv,
December 8,2010 •~- aAAW''= ' ki
McKinstry Company LLC
16790 NE Mason St., Ste. 100
Portland, OR 97230
Attn: Diane Parke
Re: Permit No. PLM2010 -00268
Dear Ms. Parke:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12447 SW 69 Ave.
Project Name: HSBC
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $269.01.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as scope of work has changed. 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 o Fax: 503.684.7297 ® www.tigard- or.gov o TTY Relay: 503.684.2772
11/03/2010 12:53 5033316907 MCKINSTRY PAGE 01/04
IN
Community Develo BECEI
atx�►en e
r c_n 1 {:` Request for Permit Action NOV 3 2010
.I, . •. I
TO: CITY OF TIGARD BUILDING DIVISION
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 El Applicant
(check one) El C On17aCIDr n City Staff
REFUND OR Name: MclKinstry Company, LLC
INVOICE TO: RBusirn:;:s or 1ndiS ;diaj
Mailing Address: 16790 N.E. Mason Street, Suite 100
City /State /Zip: Portland, OR 97230
Phone No.: Diane Parke, 503.331.2465
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION. i
® REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE. (attach case fee schedule and explain below)- ,/ /7 //b
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
/0/
Permit #: PLM2010-00268
Site Address or Parce] #: 28101AA09100
Project Name: HSBC Urinal. Replacements
Subdivision. Name: _ Lot #:
EXPLANATION: Customer changed scope of wort( from installing (1 new urinals to
only replacing the in, r pa, • of the existin: ,,, als.
Am, •
( 6u / � *_
Signature: ,- e if
Dare: 10/7/10
ane Parke
Print Name:
1. The Director or Building OFficial may authorize thc refund of;
a) any fee which was erroneously paid or collected.
b not more than &t% of the land use application fee when an Application is withdrawn or canceled before any review effort 1i lfecn expanded.
c) not more than Rfl° /ii of the land u =a applicat fcc for i;:;:ucd permit:.
d) not more than 80 of the building plan review for when an application is canceled before any plan re, -iew effort has been expended.
c) nor more than Spin of thc building purnit fcc for issue,.d permit!: Prior to any inspection roqucair.
2 Refunds will be returned to they original Payer in the same method in which. Payment was reacivcd. Picarc allow 1 -2 weehx for process refunds.
.' " � . `17 R'01 I JCL (' E ONLY'
Rte to S , s Admin: Date IMIIII Rtc o ^ to Bid_ Adrnirt: Date 7 /p B iiira
Refund Processed. /8 By <i:• .it�B�
•��.� Invoice Processed: Date By i
Permit Canceled: Date 2 / - rj rza Parcel Ta_ Added: Dare
Receipt # " • / .• , =�� Method L'
e� Amount -
1; \23uildinp \ Forms \RcgPe Re 07/26/07