Permit q
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Community Development
Request for Permit Action JAN 1 9 2011
TIGARD CITY OF TIGA53D
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: n Owner n Applicant ❑ Contractor Fl 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 ( ✓):
® CANCEL PERMIT APPLICATION. V 0 1
n REFUND PERMIT FEES (attach receipt, if available). f /�j`
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: FPS2010 -00135
Site Address or Parcel #: 11008 SW Mallow Terrace
Project Name: Village at Summer Creek
Subdivision Name: Lot #: 82
EXPLANATION: Created wrong permit type. See PLM2011- 00015.
Signature: L 1/4 i 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 Sys Admin: Date By Rte to Bldg Admin: Date / /y 4 By T7" '
Refund Processed: Date ByAgi Invoice Processed: Date By
Permit Canceled: Date / //y //� By « Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
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Building Fixtures t.a�e t is, A,��
FOR OFFICE USL ONLY ,
ge't F 7 NOV (ft Received .../
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�- City of Tigard � 2010 � > /�,
DatuB // (' (O A, . l /J/?o/t�J - �O�
,t , 13125 SW hall 131vd. Tigard OR 9722 } �y� D flan Rcylc,e Date:B): Other Peat \o.: than co raj lir . Phone: : 503.(139.4171 Fax. 503.598.1t4(1 � nu �
�h *a . Inspection Line: 503.6_,9.}175 BUILDING
TIGAR °D ��� �� � �( Date Ready /t3 : Jung: 0 See Page 2 for
1, .,t „t ,,�s
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w.tigard- or._ov Not ified ?Method: Supplemental Information
Mf 1 n'; ,:',,1:i, ' : F F t T 1 P I+'UT �WQRK` ; 'Ala a �ft i r, rt r FLN SC HCD[JI F i t
,a.x'sr_ ',;+<, , . .;1: 4 :k .., z- .50. s ,.?. ,__ liA , ',2ii:,r ;, D.i ,:, e fi <__ ears $ki ,v ,. ' ':i . ..,'r{, .A ___. <iS t: , s - --
F or s ecial in orrnation use checklist.
® New cinistniction ❑ Uemolitiom _�" f
Description Qty. Ea. 1 'fatal
❑ Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
3 r. < a -° � wrxs. � m � � % �: to - ,
f .,,z,~�,„y ,. ,„k
,' r # ( ' Or C e g , . M .
',a ,: S Fk(I)bath 312.70
® 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
SFR (3) bath 500.32
❑ Accessory building ❑ Multi=family -
Each additional bath /kitchen 25.02 1
-- ❑ Master builder ❑ Other: Fire sprinkler - 7M% sq. ft.) it Page 2i
r ; r- s= fi x. s n r I ... y . __.
t JOB SITE I rOR'VIATION tkND I OCAI'O' �� � w Sitiliti:
6 .,..�?` w n,�r ,.. . s ..�,. .�.,� s�.r�.., -.xs ak,..: _�k a,,cuw , , >. , �, . �. Via, .. . _, e • utilities. es
' - -
Job site address: HOOF' f j 1 / 4 ' « C J �CJ ' C n asin or area drain 1
DryweIl, leach line, or wench drain 18.76
City /State /ZIP: TIGAR OR, 97223 .
Footing drain (no. linear ft.: 100) 1 Page 2
Suite /bldg. /apt. no.: Project name: VILLAGE AT SUMMER CREEK Manufactured home utilities 50.03
Cross street/directions to job site: CORNER OF SW BARROWS RD, Manholes 18.76
SW 135 AVE, AND SW SCHOLLS FERRY RD Rain drain connector 1 18.76
-
Sanitary sewer (no. linear ft:: 100) 1 Page 2
Storm sewer (no. linear 0.: 100) I Page 2
Water service (no. linear Ii.: 100) I Page 2
Subdivision: VILLAGE AT SUMMER CREEK Lot no.:$, Fixture or item:
Tax map /parcel no.: Backflow preventer 31.27
ry % � ar & Back water valve 12.51
� I i ` ..
, = ' ` a-i ,
, 'IY t .,.0 DESCR1PiaT . .
iON OF WORK ;;. a . .> r ,� " -
< Clotheswasher 1 25.02
NEW 'SFR TOWNHOUSES Dishteaslier I 25.02
UNIT C 1186 SQ. F1 • Drinking fountain 25.02 1
Ejectors /sump 25.02 i
,�' dNS. d - "d' €'$ "'
1 7
it £a r ®PROPS T O)4NER &s /?f p i t K;s i® TENANT Qe x � , e [ tank 1_.51
Name: CENTEX HOMES ' ' Fixture /sewer cap 25.02
Floor drain /floor sink /huh 25.02
Address: 16520 SW UPPER BOONES FERRY RU, STE 200 "-
Garbage disposal 1 25.02
__
City /State /ZIP: PORTLAND OR, 97224 Hose bib 2 25.02
Ice maker I 12.51
a� a ` ® APPUICA,NT', �r � ` t i F a ►Z � CONT�ACi1 PERSONP - a *" Interceptor /grease trap 25.02
a � a k �
Business name: CENTEX HOMES
Medical gas (value: $ ) Page 2
Primer 12.51
' Contact name: GARY CU LP
Roof drain (commercial) 12.51
Address: 16520 SW UPPER BOONES FERRY RD, STE 200 Sink/basin /lavatory 5 25.02
City/State/ZIP: PORTLAND OR,'97224 Solar units (potable water) 62.54
Fax: : (503) 608 -3061 Tub /shower /shower pan 2 12.51
Urinal 25.02
E gary.eulp@pultegroup.com - --
t rr . h ,= ,` ��w rt vi ��Cta l� � x ; r ( -_1 sF r Water closet 3 25.02 --
r - i�r3) R O } _ O #cep. > )" , ...a.: .xr�_..A'.� ,.,.';t..`r3 -
� �.. _ ,. �, . �,.:z�a.d �. Water heater 1 37.52
Business name: CRAFTWORK PLUMBING INC. Water pipin fDWV 56.29
Address: 7737 SW CIRRUS I)R Other: 25.02
--
City /State /ZIP: BEAVERTON OR, 97008 Subtotal �
Minimum permit fee: 872.50
Plan review (25% of permit lee)
CCII I,ic.: 79666 Plumbing Lic. no.: 20- 148P13 ...
State surcharge (12% of permit fee) I
Authorized signature: f 'J .10-1 Al. PERMIT FEf.
This permit application expires if a permit is not obtained within IS() days
Print name: PETER PO1,1,ARD Date: 0,1?-/PO after it has been accepted as complete.
'Yee methodology set by Tri- County Building Industry Service Board
1 V 13uildin PerrnitApp doe IWOI'1) 440 -•i6 I tin I0 /02 /COA1/Wi131