Permit • E ceIED
•
Community Development
I IN JAN 112Q11
TIGARD Request for Permit Action CITY p
BUID111� a�VIS�o
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: ❑ 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 ( ✓): VOID
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available). /y ///
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). gpsyt__
Permit #: FPS2010 -00132
Site Address or Parcel #: 11022 SW Mallow Terrace
Project Name: Village at Summer Creek
Subdivision Name: Lot #: 79
EXPLANATION: Created wrong permit type. See PLM2011 -00012
Signature:
TI Date: 1/14/2011
D ebbie 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 Bid: Admin: Date / B 7
Refund Processed: Date /1/ /f By :PO Invoice Processed: Date By
Permit Canceled: Date ' // /// Bjs/ -- Parcel Tag Added: Date By
_ Receipt # Date Method Amount $
I: \Building \Forms \RegPermitAction.doc Rev 07/26/07
I
Plumbing Permit Applicati� i 1 g
-.. 4 14 a x , r i b 4 'r" 4i y �� 11;" Y : .. )':V `� r °+ x `` ' -D5 x' i ;e.
Building Fixtures � � : : � ��-° v �` ,FOR OFFIC USE O , ' � , ' ° x, y
{ f A d £h" t : n�, 7.0i0 S , ik i �) deir7 .. t £.w ..+' tCr...
n s City Of Tigard � ��.J�9 �J Received
! � Permit a t�A . 2
a 13125 SW Nall Blvd., Tigard, OR 97 N. DateA ti, ?4) / ' o - doC✓
-411
r Phone: 503 639.4171 Fax: 503.59:,1k01 OF TIGAR D
i
P
h
Plan Review
e,. ' Inspection Line: 5036394175
' .. DIVISION Other Permit .N o.:
TI �l�I�.��� �.<avfi.Slt„��1 Datc.'I3y: O ro',0lG
,.,,.i•;:"; _. . c Internet: www.trgard- or.gov Date ReadyiBy: Juris 17+ See Page 2 for
. Notified /Method: _ Supplemental Information I J
-s a y .v x l - s a ,� 1 ..� . > .
' >�., x ..r . � : � �.w'.. i , , ,, O W O R K ti { ;r <,a :x,M . �'. .. r
® ❑Demolit s a x � -
t ",
New construction � � z w H �CN FDU I F t t x= 't
❑ Addition /alteration /replacement ❑ Other: For special information use checklist. -
i d to x Description Qty Fa. Total - I
d �,;by II Y �- sCATFGp iV € G +N t- .�Prn 1 k Ol ( wf � � ON P k- ii k - , -�: 'fr ?l a., r � � ft. x f ,. �x i SL'RIf i ) .�a p a 3 Y New 1- 2- family dwellings (includes 100 . for each utility connection) 1 1
Eg 1- and 2- family dwelling ['Commercial/industrial SFR (1) bath 312.70
SFR (2) bath 437.78
❑ Accessory building ❑ Multi - family
SFR (3) bath 500132
❑ Master builder ❑ Other:
Each additional bath /kitchen 25.02
g ' r x y JUB` SIT1ti r'1';FORMATIOi�i A1S`D L T
OCaION f 1 r : E Fire sprinkler ( . ft.) ' Page 2
9,?1k ,k.xr „§'us. � r ..n, -.. ..,, >�n. b„.�.rx a&. «,t�` ,_. .„ ..,x-L., rou �.t . •,�_, s, ..., - a
Job site address: //lOZ ,e ,t ) Site utilities:
Catch basin Or area drain
City /State /'LIP: TiGARD' OR, 97223
DryweIl,.leach line: or trench drain 18.76
Suite/bldg. /apt. no.: Project name: VILLAGE AT SUMMER CREEK Footing.drain.(no. linear ft.: 100) 1 Page 2
Cross street/directions to job site :' CORNER OF SW BARROWS RI), Manufactured home utilities 50:03
'SW 135 AVE. AND SW SCROLLS FE RD Manholes 18.76
Rain drain connector I 18.76
Sanitary sewer (no. linear ft: 100) 1 Page 2
Storm sewer (no. linear ft.: 100) 1 Page 2
; _Subdivision: VILLAGE AT SUMMER CREEK Lot no.: -77 Water service (rur, linear ft.: 100) I ,Page 2
Tax map /parcel no:, Fixture or item:
g a n to t - r 1 x a g s r�a�x su x Backflow preventer 31.27
; ,W ; FIII tit s bF1SCRIPTfON OF WORK t .t, r
. -,z �� ,,. �.�..ta. ;:._ r,� ., t..1 {s. .,Lt Backwater valve 12:51
NEW SFR TOWNHOUSES Clothes washer 1 25.02
UNIT A 1460 SQ. FT. Dishwasher 1 25.02 ,
Drinking fountain 25.02 1
x fi .roaa Fi a R'r x""rfs e " s Jk
'4 4 .0 . ,s�`iPRQPERFI TOWkVFR ` 3 iI 4 0 TENA _f t Ejectors/sump 25.02
Name: CENTEX HOMES Expansion tank 12.51
Fixture /sewer cap 25.02
Address: 16520 SW UPPER BOONES FERRY RD, STE 200 - 1
Floor drain /floor sink /hub 25.02
City /State /ZIP: PORTLAND OR, 97224 Garbage disposal 1 25.02
Hose bib 2 25.02
14 a fvx�� fit �"a VI IK 7 y ice Maker 1 12.51
.- ;.� ',� , . APP3.ICAN3;r .. .. e r _;,. ., x . ®r e0 PEBSOI x '
Business name: C.ENTEX HOMES Interceptor /grease trap 25.02
Contact name: GARY CULP Medical gas (value: $ ) Page 2
Primer 12.51
Address: 16520 SW UPPER BOONES FERRY RD, 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 @pultegroup:com Tub /shower /shower pan 2 12.51
a r S ffr Urinal 25.02
y 'GOR ., . .x
'TiiiikaOrt �� 1 M -
.gt_.i,s��w.>M-_.x� � d..,. .,, , , ...," _.. ,�.,., m Water closet 3 25.02
Business name: CRAFTWORK PLUMBING IN(:. Water heater 1 37.52 1
Address: 7737 SW CIRRUS DR Water piping/DWV 56.29
City /State /ZIP: BEAVERTON OR, 97008 Other: I 25.02 I
Subtotal 1
- Minimum permit fee: $72.50
CCB Lie.: 79666 Plumbinu Lie. no.: 20 -148PB
Plan review (25% of permit fee)
/
State surcharge
Authorized signature: ge (12 %o('pernut tee) -
f � �
TOTAL. PERMIT Pfil:
Print name: PETER POLI.ARD Date: - (7-
I-\ i3uildin _i4Permits\Pt.MU- PCn mil App .doc 1 0/01 /29 440- 4616T(