Permit Building Permit Applicatio n ;, J
Fire Protection System r j / / � f' FOR OFFICE USE ONLY
City of Tigard RECEI ateBea Q�tC� PermitNo.5 0 / � 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review /
Phone: 503.639.4171 Fax: 503.598.1960 Date �% �� l ( 5 I I Other Permit:
TIGARD Inspection Line: 503.639.4175 OCT - 26 2010 Date Ready /By: Juris: 53 See Page 2 for
Internet: www.tigard - or.gov Notified/Method: Supplemental Information
CITY OF TIGARD
TYPE OF W1; i j ILDING DIVISION REQUIRED DATA: 1- AND 2-FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
® Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION
work indicated on this application.
❑ 1- and 2- family dwelling ® Commercial /industrial Valuation: $
❑ Accessory building ❑ Multi- family
Number of bedrooms:
El Master builder ❑ Other: Number of bathrooms:
/6 i JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address:02SVW GREENBURG RD New dwelling area: square feet
City /State /ZIP: TIGARD OR 97223 Garage /carport area: square feet
Suite/bldg. /apt. no.: 487 Project name: FARMERS Covered porch area: square feet
Cross street/directions to job site: LINCOLN 1 Deck area: square feet
Other structure area: square feet
REQUIRED:DATA: COMMERCIAL -USE, CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the
'DESCRIPTION OF WORK work indicated on this application.
FIRE ALARM Valuation: $$2,400.00 •
Existing building area: 1475 square feet
New building area: 0 square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City /State /ZIP: Existing: B
Phone: ( ) Fax: ( ) New: B
. 4® APPLICANT ❑ CONTACT PERSON
NOTICE
Business name: Safe Technology Group Inc. All contractors and subcontractors are required to be
Contact name: Jason Sweet licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 6400 NE Hwy 99 Suite G375 jurisdiction in which work is being performed. If the
City /State /ZIP: Vancouver WA 98665 applicant is exempt from licensing, the following reasons
apply:
Phone: (360) 699 -2130 Fax: : (360) 719 -1527
E -mail: sales @safetechnology.net
CONTRACTOR BUILDING PERMIT FEES*
Business name: Safe Technology Group Inc.
(Please refer.to fee schedule)
Permit fee:
Address: 6400 NE Hwy 99 Suite G375 Me/
State surcharge (12% of permit fee): / �1 , a
City/State /ZIP: Vancouver WA 98665 FLS plan review (40% of permit fee):
Phone: (360) 699 -2130 Fax: (360) 719 -1527 (Due upon application.) �t� o p
CCB lic.: 173731 Total permit fees: /557. 35
signature:
fatAuthorized ✓ e Amount received:
This permit application expires if a permit is not obtained
Print name: JASON SWEET Date: 10 -25 -10 within 180 days after it has been accepted as complete.
* Fee methodology set by Tri -County Building Industry
Service Board.
I \ Building \Permits\FPS- PermitApp.doc 10/01/09 4404613T(11/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2 - Supplemental Information
Describe work to be done:
1.) ❑ New 2.) Modification to sprinkler heads only:
❑ Addition ❑ 1 -10 heads: No plan review required.
(d} Alteration ❑ 11 + heads: Plan review required.
❑ Repair
Number of sprinkler heads:
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet ❑ Dry
Additional Standpipes
Information: Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations Al Yes
include: Individual Component g Yes
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $
Plan review requires a completed application and 2 sets of plans at submittal. Plan review fees are required at submittal.
\ \Safcscrver \d$ \ SAFE \ Forms \Use these forms \Permit Apps \ Tigard \FPS- PermitApp4e 10/01/09
•
City of Tigard, Oregon ® 13125 SW Hall Blvd. • • Tigard, OR 972
• , 13 �e':
December 8, 2010 ;•.:; t ..., =.r A
Safe Technology Group, Inc.
6400 NE Hwy 99, Ste. G375
Vancouver, WA 98665 •
Attn: Jason Sweet
Re: Permit No. FPS2010 -00124
Dear Mr. Sweet:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 10330 SW Greenburg, Ste. 487
Project Name: Farmers Insurance
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $91.57.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as Are alarm was not installed. Refund 80% of permit fees;
retain plan review fee as plan review was completed prior to request for cancellation.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
1: \Buildin Refunds \Administ ration \LtrRefund- CancelPerrnit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard - or.gov • TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
n
S 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 180621 - 12/07/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2010- 00124
5-91.57
Total: $ -91.57
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 073914 DHOWSE 12/07/2010 5 -91.57
Payor. Jason D Sweet, Safe Technology Group Inc •
Total Payments: 5 -91.57
Balance Due: $91.57
Page 1 of 1
11111 CITY OF TIGARD RECEIPT
4
. s . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 180090 - 10/26/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
FPS2010 -00124 Permit Fee - COM 2300000 -43104 $102.20
FPS2010 -00124 12% State Surcharge - Building 1003100 -24001 $12.26
FPS2010 -00124 Plan Review - Fire Life Safety - COM 2300000 - 43108 $40.88
Total: $155.34
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 073914 DADAMSKI 10/26/2010 $155.34
Payor: Jason D Sweet - Safe Technology Group Inc
Total Payments: $155.34
Balance Due: $0.00
Page 1 of 1
Er City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit /1ction form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Safe Technology Group Inc. DATE: 11/23/2010
6400 NE Hwy 99, Ste. G375
Vancouver, WA 98665 REQUESTED BY: Dianna Howse
Attn: Jason Sweet
TRANSACTION INFORMATION:
Receipt #: 180090 Case #: FPS2010 -00124
Date: 10/26/2010 Address /Parcel: 10300 SW Greenburg, Ste. 487
Pay Method: CreditCard Project Name: Farmers Insurance
EXPLANATION: Per applicant's request as no fire alarm was done. Refund 80% of permit fees; retain
plan review fee as plan review was completed prior to request for cancellation.
REFUND INFORMATION:, :
Fee Description From: Receipt .. • • Revenue Account-No: - Refund • Example: Building Permit Fee - • E*ample: •2300000. 43104. . .$ Amount
FPS Permit Fee 2300000 -43104 $81.76
12% State Surcharge 1003100 -24001 9.81
TOTAL REFUND: $91.57
APPROVALS:
I f 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: 4x/2//0 I B I A
•
I: \Huildin \Refunds \RefundRc t.doe x09/01/2010
t Celieb
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: I ' Community Development e C1�'OF
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Request for Permit Action U1 � D 1 NG p
-SO
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www,tigaed- or.gov
FROM: [] Owner [I Applicant 5' Contractor 0 City Staff
(cheek ring)
REFUND OR Name;
INVOICE TO: Ohlinsuar h )
M a i l i n g Address: L G1O o G� t 3 •-
City /State /Zip: G _cac.Wif td /f 9 'C&AS
Phone No.: _ 3&O'' (wig . 1310
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
. CANCEL PERMIT APPLICATION. V 0 I
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 #: rp5 10 oo
Site Address or Parcel #: _f0 30 b (2 6
Project Nance: FA -�►.Su GP.
Subdivision Name: Li GD( vl Off Lot #:
EXPLANATION: Nt, rt I G nn Uc���O�
t ; & J CO - ! or La
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Signature: Date: l/� +y_ /0
Print Name:
1. The Dimmer or Building Officer may euthndae the re8md of:
a) any fee which was eesoneotdy paid of collected.
c ) not more than 80% of the rand too app8oidoe fee when an application is withdrawn or canceled before
) not moan than 80% of the land use application fee for issued permits. wry eevie w ellSaet barn been
ti) not more than 80% of the btnldutg plan review fee when an application is canceed before any plan 2 Re will be than 8 0 budding pcmmit he for issued permit': p,ior to any inspection m review either has been m�Pen da
original Pay er in the tame method in which wont wee tot d . Me ec a@ow 1.2 weeks foe proassmg refunds.
I t i l t f!I 1 I( I IN, 1 )i\ i
Rte to S • s Admin: Date
Refund Ptoo�ed Date ' y M'. Rte to :+' • Adreid; Date // � �
°�' ' °.ate invoice Processed:
Permit Canceled: Date ► i Parcel To Added: Date Mann
I: ice . • MISS • . Pet►nir I it� f . a ,.s P��► EMI=