Permit ' I1
%1GAattDh
City of Tigard
January 6, 2012
Frederick Payne
4740 SW Lowell Ct.
Portland, OR 97221
Re: Permit No. BUP2011 -00019
Dear Mr. Payne:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12511 SW 68 Ave.
Project Name: HP Northwest
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $106.92,
Note: Please allow 2 -5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of $ .
Comment(s): Per applicant's request as work was not performed. Refund 80% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely, - '
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Buildin \Refunds 125, -S li aftteR rads ®ftgnn 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
CITY OF TIGARD RECEIPT
II
13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
TIGARD
•
Receipt Number: 185097 - 01/06/2012
CASE NO. FEE DESCRIPTION REVENUE ACC OUNT NUMBER PAID
�
V
BUP2011 -00019 / M � i /�� � , A 30 -0060 - L/3 /0 y $- 106.92
/2 71 S7;7r-S- u2Cff. / 0 4 ` 3/60 " .540e)/ Total: $-106.92
/7,4# /0 O CLOUD - VCOO
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 001641 DHOWSE 01/06/2012 $- 106.92
Payor: Frederick Payne
Total Payments: $- 106.92
Balance Due: $106.92
Page 1 of 1
CITY OF TIGARD RECEIPT
II
R - 13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
TIGARD -
Receipt Number: 181259 - 01/27/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
BUP2011 -00019 Permit Fee - Additions, Alterations, 2300000 -43104 $119.33 &-
Demolition
BUP2011 -00019 12% State Surcharge - Building 1003100 -24001 $14.32 ('"-
BUP2011 -00019 Plan Review 2300000 -43106 $77.56
BUP2011 -00019 Plan Review - Fire Life Safety 2300000 -43108 $47.73
BUP2011 -00019 Info Process /Archiving - Sm Sheet (up to 2300000 -43135 $0.50
11x17)
Total: $259.44
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 001641 BTAGGART 01/27/2011 $259.44
Payor: Frederick Payne
Total Payments: $259.44
Balance Due: $0.00
• Page 1 of 1
: City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request forPermit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Frederick Payne DATE: 1 /4/2012
4740 SW Lowell Ct.
Portland, OR 97221 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 181259 Case #: BUP2011 -00019
Date: 1/27/2011 Address /Parcel: 12511 SW 68th Ave.
Pay Method: CreditCard Project Name: HP Northwest
EXPLANATION: Per applicant's request as work was not performed. Refund 80% of permit fees.
.YND`INFORMATI i - ,, , - Mt g. `
�WN
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r Fee Descnpt>ion 0 Rece W ` A Revenue Account•No . "Refund
x , .'�-. ,.;�` c '�.`�?'Yi'..tyy N� �- � .� y .,^.' - y �,x- T�kn.�� ,.'�€*' -� .s �- s+�1� €:�-�&� "WON
`�
:Examplg �.Bnildtng Perrit,Fee yN �s -. aISIe;� 431,04 - Amount
Building Permit Fee 230- 0000 -43104 $95.46
12% State Surcharge 100 - 3100 -24001 11.46
TOTAL REFUND: $106.92
- APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager 14(Akk
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
� ���"i��s.�?�- ���5 -�. .3' - - - - - - ,.,' - - -- - -: : °- - ; � ��- .`
v ,,; SAVE ; �SFOR TIDEMARK SYSTEM,ADNIINISTRATIO,_Nr5ti O,NI:Y, � � .,
Case Refund Processed: Date: / ( a 2 B : AIIR y
I:\ Building \Refunds \RcfundRcyuest.doc x 09/01/2010
•
1 it,
Community Development 0 1 0
Request for Permit Action / /j
,
TIGARD
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: , ! Owner cant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) �/ R. ph-»,v4
Mailing Address: th y p 1 L) I._e"wC LL- c.._-r-
City /State /Zip: W al /..)* D2 47? -'oZ/
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
IS CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: i3LL( ao 1 l - cob 1
Site Address or Parcel #: 1 a 5 I l t, LPQ PiU F,
Project Name: 4P 7.)012.rit W tx.
Subdivision Name: Lot #:
EXPLANATION: Loo 13 eJ EC "Do(Jt..., ,
■
. ffrA'
Signature: I 7 Date: f -g- 4 Print Name: 4 yfvF
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 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date /,A fill= KAMM Rte to Bld• Admin: Date/�� B 4Y ?'
Refund Processed: Date / , 451, B 4 i Invoice Processed: Da - By
Permit Canceled: Date , -A ,Affl om.m. Parcel Ta: Added: Date B
Receipt # Date Method C. ( Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 04/26/2011
N. r� CITY OF TIGARD BUILDING PERMIT
c COMMUNITY DEVELOPMENT Permit #: BUP2011-00019
13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/27/2011
T I GARL� Parcel: 2S101AA08700
Jurisdiction: Tigard
Site address: 12511 SW 68TH AVE
Project: HPNORTHWEST Subdivision: WEST PORTLAND HEIGHTS Lot: 29
Project Description: TI
Contractor: OWNER Owner: BEVELAND BUILDING LLC
4740 SW LOWELL CT
PORTLAND, OR 97221
PHONE: PHONE:
FAX:
FEES
Specifics: Description Date Amount
Type of Use: COM Permit Fee - Additions, Alterations, 01/27/2011 $119.33
Class of Work: ALT Demolition
Dwelling Units: 0 12% State Surcharge - Building 01/27/2011 $14.32
Stories: 2 Height: 0 ft Plan Review 01/27/2011 $77.56
Bedrooms: 0 Bathrooms: 0 Plan Review - Fire Life Safety 01/27/2011 $47.73
Value: $3,000 Info Process /Archiving - Sm Sheet (up to 01/27/2011 $0.50
11x17)
Floor Areas:
Total Area: 0
Accessory Struct: 0
Basement: 0
Carport: 0
Covered Porch: .0
Deck: 0
Garage: 0
Mezzanine: 0
Total $259.44
Required: Required Items and Reports (Conditions)
Fire Sprinkler: Parapet:
Fire Alarm: Protected Corridors:
Smoke Detectors: Manual Pull Stations:
Accessible Parking: 0
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law ' requires you to follow the rules adopted by the Oregon Utility Notification Center. hose rules are set forth in OAR
1 0) 952- 001 -0010 through O • : 952- 001 -0090. You may obtain a copy of direct questions to OUNC by calling 503. • 00.332.2344.
Issued By: ,, ` � ` - Permittee Signature: rw / __
.... 175 by 7:00 a.m. for the next available inspection da e. ' -
This permit card shall . • ept in a conspicuous place on the job site until completion of the pro .
Approved plans are required on the job site at the time of each inspection.
Building Permit Application
C'Oill RECEIVE,` FOR OFFICE USE ONLY
City of Tigard DateBv , a--)jr, Permit No.: ip,, - OCk9J
't 13125 SW Hall Blvd., Tigard, OR 97223 AN 2 7 ?MI Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date /B : 27- / Other Permit:
TI G ARD Inspection Line: 503.639 CITY OF TIGARD Date Ready /By: ®See Page 2 for
Internet: www.tigard or.gov Notified/Method: Supplemental Information
BUILDING DIVISION
`' e>'E®F WORK ` Ka t' .t y', , REQU RI ED DATf1 1 AND 2 FAMILY DWELI:ING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
® Addition /alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
f wor indicated on this application.
•
CATEGORY OF CONSTRUCTION PP
❑ 1- and 2- family dwelling ® Commercial /industrial
Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
F "JOB SITE I FORMATION AND LOCATIO Total number of floors:
Job site address: 12511 SW 68 Ave New dwelling area: square feet
City /State /ZIP: Tigard, OR 97223 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: Lobby Security Covered porch area: square feet
Cross street/directions to job site: Beveland & 68th Deck area: square feet
72 " Ave North to Beveland; East on Beveland to 68` north on 68 to first Other structure area: square feet
driveway on left REQUIRED RATA COMN1E�i USE C HECKL
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: equipment, materials, labor, overhead, and the profit for the • t DESCRIPTIONOF' WORK 00 - work indicated on this application.
Add a door to isolate lobby from rest of building Valuation: $53,000.00
Existing building area: square feet
New building area: square feet
® PROP OWNER = , TENANT pis Number of stories:
Name: The Beveland Building, LLC Type of construction:
Address: 12511 SW 68th Ave Occupancy groups:
City /State /ZIP: Tigard, OR 97223 Existing:
Phone: (503)597 -1600 Fax: (503)597 -1621 New:
y
APP�II CA ❑ CO
�. u `��`��,
Business name: Heintzberger Payne All contractors and subcontractors are required to be
Contact name: Fred Payne licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 12511 SW 68 Ave jurisdiction in which work is being performed. If the
City/State /ZIP: Tigard, OR 97223 applicant is exempt from licensing, the following reasons
apply:
Phone: (503) 597 -1621 Fax: : (503) 597 -1649
E -mail: fredp @HeintzbergerPayne.com
1 c y a i i i ��-a•T�,.-',
•
Business name: Owner ASV BUILDINGPERMITFEES�'
( 1`eas ere,Jertofeescheduie)' . x ......: t. .
Address: 12511 SW 68th Ave
Structural plan review fee (or deposit):
City/State /ZIP: Tigard, OR 97223
FLS plan review fee (if applicable):
Phone: (503) 597 -1600 Fax: (503) 597 -1621
Total fees due upon application:
CCB lie.:
• Amount received:
Authorized signature: L( l This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Ed Heointzberger Date: 1/27/11 * Fee methodology set by Tri- County Building Industry
Service Board.
I: \Building\Permits\BUP -COM PermitApp.doc 10/01/09 440- 4613T(I1 /02 /COM /WEB)
I q B uilding Division
Over- The - Counter (OTC) Building Permit
TIGARD Check List
Project Description:
APPLICATION SPECIFIC INFORMATION
GENERAL INFORMATION r
*Class of Work: A Occupancy Group: Type of Construction: 44i
*Type of Use: 00./A Occupancy Load: 1.11Cr. Oregon Specialty Code: �j,i
SPECIFICS
Number of Stories: Building Height: Mixed Use:
Number of Dw Units: Number of Bathrooms: Number of Bedrooms:
BUILDING SQ FT - SCHOOL CET OTHER SQUARE FOOTAGES
Story Square Footage: N/4 Accessory Structure: Covered Porch:
Basement: Garage: Deck:
Total Square Footage: Carport: Mezzanine:
SETBACKS A, A
Sideyard Setback — Left ' V Sideyard Setback — Front
Sideyard Setback — Right Sideyard Setback — Back
CONSTRUCTION N A
Exterior Walls: Openings Protected: Firewall Separation:
N: S: N: S: Occupancy Separation:
E: W: E: W: Access. Parking Spaces:
REQUIRED ITEMS N l/it
Fire Sprinklers: Fire Alarms: Smoke Detectors:
Parapet: Manual Pull Stations: Protected Corridors:
Total Project Valuation: $ FEES DUE
$ DC Prov Rvw, COM TI — Ping
$ DC Prov Rvw, COM TI — LRP
DC Provision Review Fee for COM TI $ X Permit Fee — Add, Alt, Demo
Project Valuation P1 $ 12% State Surcharge
Up to $4,999 $0.00 ' $0.00 $ Plan Review, Structural
$5,000 - $74,999 : ' .00 - i - .10 $ ) Plan Review, Fire Life Safety
$75,000 - $149,999 $160.00 $24.00 $ Info Proc /Arch, Lg (over 11x17 $2.00)
$150,000 and over $256.00 $38.00 $ / Info Proc /Arch, Sm (up to 11x17 $0.50)
$ Metro Construction Excise Tax
$ School Construction Excise Tax
$ Hourly Rate Fee
Planning Staff: G 1 $ Hourly Rate State Surcharge
$ Misc. Admin Fee
Permit Coordinator: As $ Other:
$ Other:
Building Staff: PIAV/ $ Other:
Date /Time: 1 7 /0: co $ TOTAL FEES DUE
*OPTIONS:
TYPE OF USE: COM = commercial; CMS = commercial manufactured structure.
CLASS OF WORK ACS = accessory; ADD = addition; ALT = alteration; FND = foundation; DEM = demo;
FND = foundation; FPS = fire protection system; NEW = new; OTR = other (use for fences, decks, retaining walls, signs, awnings or canopies);
REP = repair.
I: \ Building \Forms \OTC - BUP.docx 01/13/2011
Building Division
Development Code Provision Review
TIGARD Commercial Projects - No Associated Land Use Case
Building Permit No: / f O(/-000 (? ' Expedited Review
Plan Submittal Date: / 7:7 i/
To the Applicant:
If the proposed use is not permitted within the zone, please contact the Building Division to cancel
the permit application. Building Permit Technicians (503) 718 -2439.
If a land use is required and for all other questions, please contact the staff person listed above the
Planning Review section.
Staff: please check items along left only if approved.
Planning Review (contact at at 503 -718- or @tigard - or.gov)
❑ Zoning Permitted Use Yes ❑ No ❑
❑ Land Use Required: Yes ❑ No ❑ (explain below)
Notes:
*Approved ❑ Not Approved Date: $
Permit Coordinator Review (contact Albert Shields at 503- 718 -2426 or albert @tigard - or.gov)
Notes:
Routed back to Building Division Date: //
I: \CURPLN
O-T-C CITY OF TIGARD
OFFICE COPY A ppr oved P
Occupancy Type -i Conditionally Approved
Occupancy Load See Letter to: Follow
A.(103 aDIdlo Construction Type Att bed
Rated Corridor
�8 Permit Number: A a y i l - QOM J
Energy Code
Accessibility Address: 1t •sw gg 1__
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