Permit ii Cr% Pam
RI
INI ' C V E D
Community Development I
TIGARD Request for Permit Action JAN ill
2011
CI
ILDING
TO: CITY OF TIGARD DIVGS'pN
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 n Applicant n Contractor ® City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): 1s 0 1 D
CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
n 77/r/7/
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). 441----
Permit #: FPS2010 -00136
Site Address or Parcel #: 10998 SW Mallow Terrace
Project Name: Village at Summer Creek
Subdivision Name: Lot #: 83
EXPLANATION: Created wrong permit type. See PLM2011- 00016.
Signature: / ' Date: 1/14/2011
Debbie Adamski
Print Name:
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 B Rte to Bld• Admin: Date /47401 B fa,"
Refund Processed: Date _A67 B ,4 Invoice Processed: Date B
Permit Canceled: Date ; MU B ' -q,- Parcel Ta. Added: Date B
Receipt # Date Method Amount $
I: A Building \ Forms \RegPermitAction.doc Rev 07/26/07
Plumbing Permit A licati ra 7010 Received
� �
Building Fixtures I k, > 11 Vi i an , 'a < t y ,. - ;
r i
g d �:, .r. ,.. e , Ran MFOR IFFI I1 O NL .: r.
.„ ta v.i s •} - . , : x resai ,, 64. , ' , . . � l: a .;� - x4,xff .;� :mui,.
a C) Of Tigard NOV ) '701 ,
`J g t / / / perm" No
'-i ;. a 13125 SW hall Blvd., Tigard, OR 97223
Date/By: g (� j o /(��Q - �13�0
Phone: 503.639 4171 Fax: 503.59 l96(9 -r t" Plan Review `(,
a s s Ins e ction Lin e: 503. 639.4175 V6 b i V � 1 ` Other Permit No.t ,7 - / f 7 OOC Oo
?1CrARD P' Date!By:
Internet: www.tigard or.gov BUILDING DIV i SlON Date Ready /By. kris. RI See Page 2 for
Notified /Method: Supplemental Information
fi s t £_ ,i r ;. T Iij W OR K . : ii
J - f eb 5 .a. �wk^ ,.siii' 3,i , a,�+V..r n. k4' .. vItEint , ' a„ 3.:: ::
,..d 2 $ '., � 3 f kf N S J� A t N
® New construction ❑ Demolition n �t �AkE * SGEII DUI Fmx� (' ,
❑ Addition /alteration /replacement ❑ Other For special information use checklist.
Description Qty. I L a 'Total -
k ' ` '': "V 4 CITR"t FGO 0 (ONSTRt3CT1()N s pm m;; N 1- 2- family dwellings includes 100 ft. for each utility connection) ,
I- and 2- family dwelling ❑ Commercial /industrial SFR (1) bath 312.70
SFR (2) bath 437.78
❑ Accessory building ❑ Multi- family •
SFR (3) bath 500.32
❑ Master builder ❑ Other: 1
� Each additional bath /kitchen 25.02
, . _,. t� "+ jO ySITk P EO i T1U ry r A D LOLA ii c � P % s , -I Fire s rinkler I aV60s 0.) Page 2
Job.si_te address: /0 g/ 7 ee - Site utilities:. . I
Catch basin or area drain 18:76
City /State /ZIP: TIGARD OR, 97223
Drywell, leach line. or trench drain 18.76
Suite /bldg. /apt. no.: Project name: VILLAGE A 'T SUMMER CREEK Footing drain .(no. linear ft.: 100) I Page 2
Cross street/directions to job site: CORNER OF SW BARROWS, RD, Manufactured home utilities 50.03
SW 135'" AVE, AND SW SCFIOLLS FERRY RD Manholes 18-76
Rain drain connector I 18.76
Sanitary sewer (no. linear ft.: 100) 1 Page 2
Storm sewer.(no: linear ft.: 10(1) 1 Page 2
Subdivision: VILLAGE AT SUMMER CREEK Lot no.: fap Water service (no. linear ft.: 100) 1 Page 2
Tax map /ptarcel no.: • Fixture or item:
t ?'4 . " k iaiiD� ' SCRIPI ION QF WORief ' i & o- " t " ,' Backflow preventer 31.27
- V:i ?,: - . ,,:;x . ._ :, o.. ...,, .x:t i z. - s p'2 .4' M .' Backwater valve 12.51
NEW SFR TOWNHOUSES Clothes washer I 2502
UNIT A 1460 SQ. F1'. Dishwasher 1 25.02
Drinking fountain 25.02
r p > , -1 ® liY tOWNFR 8 , - 6 TENANT E . r.
-
Name: CENTEX HOMES Expansion tank 12.5.1
Fixture /sewer cap 25.02 I
Address: 16520 SW UPPER BOONES FERRY RD., STE 200 Floor drainlfloor sink/hub 25.02
City /State /ZIP: PORTLAND OR, 97224 Garbage disposal 1 25.02
Nose bib 2 25.02
tq ; U " gi i � 1. " t •r * � > t ® CO NTAC T( PERSON `; - ". Ice maker 1 12.51
Business name: CENTEX HOMES Interceptor /grease trap 25.02
Medical gas (value: $ ) Page 2
Contact name: GARY CIiLP
Primer 12.51
Address: 16520 SW UPPER BOONES FERRY RI), STE 200 Roof drain (commercial) 12.51
City /State /ZIP: PORTLAND OR, 97224 Sink/basin/lavatory 6 25.02
Fax: : (503) 608 -3061 Solar units (potable water) 62.54
E- mail: gary.culp(apultegroup.com Tub/shower/shower pan 2 1251
r = F Urinal 25.02
", �r' 01 :0** 1�`,.� GOV1'RACTOR g .. ( c.
'. , �. %CC ~g "' ., .. .
,, t< 2
Water c 3 5.02
Business name: CRAFTWORK PI.,UMBING INC. Water heater 1 37.52
Address: 7737 SW CIRRUS DR Water piping/DWV 56.29
I
City /State /ZIP: BEAVERTON OR, 97008 Other: 25.02 I
Subtotal
Minimum permit fee: $72.50
CCB Lie.: 79666 Plumbino Lie. no.: 20 -148PB
./ Plan review (25`%, of permit fee)
Authorized signature: ,' ' ,r � St surcharge (12% of permit fee)
/ _ I'O'1'•Al_ PERMIT FLIT
I'rint name: PETER POLLARD Date: °°
1A nuiIdine \Permits`.I'I,\tt'- Per mil App.doe ID /01109 440- 461611,10/02/C0M/WEB)