Permit 11 • Community Development
i r D
TIGARD Request for Permit Action JA N 1 V 2 011
BU ILD , N G D! tI 1 t
TO: CITY OF TIGARD IS IQp,1
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 ❑ 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 (1):
® CANCEL PERMIT APPLICATION. VO I D
❑ REFUND PERMIT FEES (attach receipt, if available). // , /,
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). /
-
II] REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: FPS2010 -00134
Site Address or Parcel #: 11016 SW Mallow Terrace
Project Name: Village at Summer Creek
Subdivision Name: Lot #: 81
EXPLANATION: Created wrong permit type. See PLM2011- 00014.
Signature: 1 • * • 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 poor 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 L /V& By,,\�;
Refund Processed: Date /V /4 By 4 # —, Invoice Processed: Date By
Permit Canceled: Date 0y/, By = Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPerrnitAction.doc Rev 07/26/07
Plumbing Permit Application ' - , yey-*II5t0 h
R ! �` d' k � s' F f � €. t a �u � r t
I�ULlding Fixtures res Ir 1 - 2 : t ' , 4 ; V (i$ 4 .
t, �`- t � � b 4 OR�OFFICE USE ONLY �� � �
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r ) Received
�4 < City SW / //y�,..) `3
°F NOV }� f O pate /t3) : / 0 Permit No (.V
13125 SW Hall Blvd., Tigard, qR 97223 =��� i f_E. Plan Review
;€ %1 Phone: 503.639A 171 Fax: 503.598.196 Other Permit No. j/ f 0 /(j. -Q 3 ( 7T
DaterBy.
"'t ti � 3 it'; Date Ret
TIGAR ti Inspection Line: 503.639.4175 Ci h .� OF ut�{ tr ct}lk3v rains 0 See Page 2 for
Internet. N vvvvvt h2ard or Gov
BUILDING. �� '} Notified /Method
�, D t 1 Sup plementil inform 3bon
g , )t, h� l F TYPC1OI� WORN i � . `. 1 ._, -; - 3 ; =fs F I"A. ��.),g d LE * rSCF - IL.DULM e i i`rri.,. ,M ss '
l in special For s ormation use checklist
New construction ❑ Demolition P
Description Qty. Ea. I Total
❑ Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
a ..i. ' . < V CAi FGORY ON
,CaS T, ,,, )
I(Nk..,.:, ` . S FR(I)bath 312.70
.,..,.,,
® i- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78
❑ Accessory building SFR (3) bath 1 500.32 500.32
❑ Multi- family
Each additional bath /kitchen 25.02
❑ Master builder ❑ Other: Fire sprinkler q
P (J 33�s . ft.) Page 2
" a i (, f !JOB .SITE) FORi AT4D' LOCATION t � r xt`a'� ; ` Site utilities:
//0/ /, -� mi l�,�r tD 1 C basin or area drain 18:76
Job Site address: (� � 7 �,(�vlJ
Drywell, leach line, or trench drain 18.76 •
City/State/ZIP: 'i'IGARD OR, 97223 Footing drain (no. linear ft.: 100) I Page 2
Suite /bldg. /apt. no.: 1 Project name: VILLAGE ATSUMMER CREEK Manufactured home utilities 50.(13
Cross street/directions to job site: CORNER OF SW BARROWS RI), Manholes 18.76
SW 135 AVE, AND SW SCHOL.LS FERRY RD Rain drain connector 1 18.76
Sanitary sewer (no. linear ft.: 100) 1 Page 2
Storm sewer (no. linear ft.: 100) 1 Pane 2
Water service (no. linear It: 100) I Page 2
Subdivision: VILLAGE AT SUMMER CREEK 1 Lot no.: 8 1 Fixture:or item:
Tax map /parcel no.: Backflow preventer 31.27
t ,�, r L)ESCRiPTIOI o WOItIf i � , ` 1 z y . ' ' , '
„, Backwater valve 12,51
Clothes Washer I 25.02
NEW SFR TOWNLIOIiSES
Dishwasher I 25.02
UNiT B 1332 SQ. FT. Drinking fountain 25.02
. Ejectors /sump 25.02
`- ® 4I'ROPETiTY ,8 ` � ❑ `TENANTS Expansion -tank 12.51
Name: CENTEX Fixture /sewer cap 25.02
Floor drain /floor sink/hub 25.02
Address: 16520 SW UPPER BOONES FERRY RD, S'I'E 200
Garbage disposal 1 25.02
City/State /ZIP: PORTLAND... OR, 97224 Hose:bib 2 25.02
Ice m aker 1 12.51
;) z, x °� v- ry'gka ra g ,�.� n r d sa su x - e x r4;„.i '
s m ®APPLICANT r� ®CONTACT PERSON 4 interceptor /grease trap 25.02
Business name: CENTEX HOMES Medical gas (value: $ ) Page 2
Primer 12.51
Contact, name: GARY CUI;P
Roof drain (commercial) 12.5'1
Address: 16520 SW UPPER BOONES FERRY RD, STE 200 Sink/basin /lavatory 6 25.02
City /State /LIP: PORTLAND OR, 97224 Solar units (potable water) 62.54
Fax: : (503) 608 -3061 Tub /shower/shower pan 2 12.51
E -mail: gary.culppultegroup.com Urinal 25.02
4 ?, r p r yr , - - s -n ' Water closet 3 25.02
'e t.,,,',,z ., . ., 4 (O t 1,� .. ,,.r� � ,,. ^ , {
„„', _ . .w . o, s .
z Water heater ( 37.52
Business name: CRAFTW'ORK PLUMBING INC. Water pipine/DWV 56.29
Address: 7737 SW CIRRUS DR Other: 25.02
City /State / /II': BEAVERTON OR, 97008 Subtotal
Minimum permit tee $72.50
CCB Lie.: 79666 Plumbing Lic. no.: 20 -148PB
Plan review (25% of permit ice) - -_ -_�
/ 9
A State surcharge (12 °/0 of permit fee)
Authorized signature: -- r7 ,, /!sj"`� I0 "C\L. PI:RMff FEE
lt.r✓ This permit application expires if a permit is not obtained within ISO days
Print name: PETER POLLARD Date: after it has been accepted as complete.
'Fcc methodology set by Tri- County Building Industry Service Board
i. 03uiIdim±1Pen sTI,N1. - 1'crmitApp. doe 10101109 440- 4616T(10 /02JCOM /WEB)