Permit �
t s rev a v l r�
II Community Develo ment
y p JAN 142011
TIGARD Request for Permit Action
CITY OF TIGA3D
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 ❑ 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.
n /�� ///
REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: FPS2010 -00133
Site Address or Parcel #: 11018 SW Mallow Terrace
Project Name: Village at Summer Creek
Subdivision Name: Lot #: 80
EXPLANATION: Created wrong permit type. See PLM2011- 00013.
Signature: _ i 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80 °/u 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 Bld! Admin: Date /AWAM : NF
Refund Processed: Date /V //9 By Invoice Processed: Date By
Permit Canceled: Date /1/0/ By d __ Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \I corms \RegPermitAction.doc Rev 07/26/07
" L U Plumb i ng Permit Applicat - C .�„
Building Fixtures C t ! t� I( � r � ,:6��v
(,js a§d,! f ' „ :> 2,OFR(QFICEF'US UNLY' r.1 , � x t '
City of Tigard Cr iv < OF 1 Penn ��.:
h I ° i�� ° r /+ Q /�o 70/355
s � , ARE, Date/By: jl 7 �� � l /�Or �0� /
II 13125 SW Ha ll Blvd.. Tigard, OR 978 Hill �� f�+ Plan Rcvic y �jy� (
r, e If C DIVISION Other Permit No.)1/�t 67'76
a I hone. 503.63)A171 lax: 503.593.1 Date<Hy
" I Inspection line: 503.6394175
TIGA io" D ate R eady /Bq: S urls'. RI See Page 2'for
jk.„ .,,t Internet www.tigard Notified /Method: Supplemental Information
Y ';i5-';71.-4`.1:;),'7::"', 3s :O q - F eq ,�. 8. , i i anw d {
�� , � - s ' . �l TYTE OF WORK E Y t t : e ;l '' •D t H rid
l; S( [1 H U
® New construction ❑ Demolition For special information use. checklist. I
Description ] Qty. Fa. 1 'Iota)
❑ Addition /alteration /replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
0 , : - A, r' ?Cr' 1TFG0t2k Y At ' , ', SI=R (I)hath 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 I
❑ Master builder ❑ Other: Fire sprinkler 1 ft.) I Page 2
b is. )
ae ' ' , JOB SITE ,INI OR fA�TIO\ ANDP I UC ' v r 4 . ° ,t,, 6 Site utilities:
es:
, i , i
-1. Job site address: ,r�
Catch basin or area drain 18.76
�w�� /14/1,66020 K Drywell, leachaine, or trench chain 18.76
City /State /Z1P: TIGARD 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 RI), Manholes 18.76
SW 135 AVE. AND SW SC :HOLLS 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 11.:. 100) I Page 2
Subdivision: VILLAGE AT SUMMER CREEK Lot no.: Fixture or item:
lax map /parcel no.: Backflow preventer 31.27
" f 7 ilfi e ia bDESCRIPTIU OF WORK' F NN f Backwater valve 12.51
. (:" .._x,.:s .tint; .._ .. „ k,.. -. , w ,a,.rr.ar,._ ,. ., -=ix s,a,,.�.�a1. ..z.. s,„, - �. .5 ?r- '::ta' es 25
Clothes vaSher 1 25.02
NEW SFR TOWNl-1OUSES
Dishwasher I 25:02
UNIT C 1186 SO. FT. Drinking-fountain 25.02
Ejectors /sump 25.02 a
elk �
i PRO PER7- Y O�YN ( , � x i 'TENANT t � 4, v ` y Expansion tank 12.51 1
xxt ..i . , >. x _re .= . rrar ,
Name: : CENTEX HOMES S Fixture /sewer cap 25.02
Floor drain /floor sink /hub 25.02
Address: 16520 SW UPPER BOONES FERRY RI), STE 200
Garbage disposal 1 25.02
City /State /LIP: POR'T'LAND OR, 97224 Hose bib 2 25.02
lee maker I 12.51
i x.ts r�a�x "'° x (; .,c r .- r i rr �, 2"
s, "¢ � ( ®APP] 1CANT , ) g drl ®i CONTAC +r,� y interceptor / trap �.
0
Business name: C ENrTEX 1iOMES Medical gas (value: $ ) Page 2
Primer 12.5 I
Contact name: GARY CULP
Roof drain (commercial) 12.51
Address: 16520 SW UPPER 130ONES FERRY RI), STE 200 Sink/basin/lavatory 5 25.02
CityJState /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-mail: gary culpr pultegroup eom --
,� r r _z ,g .r+ inn s- t' r s *` Water Closet 3 '7 i.01 I
93 _ x ti- 7 CONTRAC1tO l i x i ' u . 7
. `„ ll„ „ , ., ..Rl %: x�A:k a n. r ,,?=. ,,,b. .t a.r a9_,...., > g• - .V: ..�, :• %,, ;!. ,7";.1.0 Water heater I 37.52
Business name: CRAFTWVORI< PLUMBING INC :. Water piping/DWV 56.29
Address: 7737 SW' CIRRUS I)R Other: 25.0
- V
City /State /ZIP: BEAVERTON OR, 97008 Subtotal
^
Minimum permit fee: $72.50
Plan review (25% of permit fie)
CC13 F.ic.: 79666 Plumbing f,ic. n o.: 20 -148PB __. - /7
A State surcharge (12% of permit fee) .
Authorized si tature: 'TOTAL PERMIT Flab „
This permit application expires if a permit is not obtained within 180 dugs
Print name: PE'11;12 P01.1 Date: 0-1?-(0 after it has been accepted as complete.
'Fee methodology set by 'Fri-County Building Inductly SCVICC HOW d.
I`.ituilai'ra,I ' e miisAPLAtl;- PermitApp.doc 1001199 440- 1616T(I o /02'CO 1 \oi)ii)