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Permit no City of Tigard June 16, 2011 Wyatt Fire Protection Inc. 9095 SW Burnham St. Tigard, OR 97223 Re: Permit No. FPS2011 -00046 Dear Applicant: • The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 12677 SW Mount Vista Ct. Project Name: Arlington Heights No. 3 Job No.: N/A Refund: ® Check #202562 in the amount of $220.82. • ❑ Credit card "return" receipt in the amount of $ ❑ Trust account "deposit" receipt in the amount of $ Notes: Per applicant's request as builder changed building,plans and resubmitted under FPS2011- 00059. Refund 80% of permit fees. If you have questions please contact me at 503.718.2430. Sincerely, / Dianna Howse Building Division Services Supervisor Enc. I: \Buildin �SAYAHafal icez'a ordo on 97223 0 503.639.4171 TTY Relay: 503.684.2772 ® www.tigard or.gov II u (YI City of Tigard T I G A RD Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit 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: Wyatt Fire Protection Inc. DATE: 6/10/2011 9095 SW Burnham St. Tigard, OR 97223 REQUESTED BY: Dianna Howse Debbie Adamski TRANSACTION INFORMATION: Receipt #: 182156 Case #: FPS2011 -00046 Date: 4/14/2011 Address /Parcel: 12677 SW Mount Vista Ct. Pay Method: Check Project Name: Arlington Heights No. 3 EXPLANATION: Per applicant's request as builder changed house plan and resubmitted under FPS2011- 00059. Refund 80% of permit fees. REFIII�ID' I;pN:. • �::;�:: l: r ,. : :.;. , - :�mK`: . 'v'',.• . ° ?�5;'r_n' __ -.3 _a�_. . :�:.• _ +;,;.!•.c ar... �iS + = F ee D c >t - ,. - ,: P., �.`� Reveiifue:Acico „ -s;a • ??' .:: 'r� - Extitrl • 1 2 Exarii ie ]. ): 0000 ?,0 04 Permit Fee . •- P. ... .. �". 2300000 -43104 $197.16 12% State Surcharge 1003100 -24001 23.66 TOTAL REFUND: $220.82 APPROVALS: /� If under $5,000 Professional Staff CK—)A,61+1-4, .Q 0 i f If under $12,500 Division Manager If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board • .:!:;FOR.TID.EMARK-,SYSTEM ADMINISTRATION • Case Refund Processed: I Date: 4/,27,/ I B I _49/71--- I:\ Building \Refunds \RcfundRcqucst.due x 09/01/2010 CITY OF TIGARD RECEIPT ` IS 13125 SW Hall Blvd., Tigard OR 97223 • 503.639.4171 TIGARD Receipt Number: 182937 - 06/21/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID FPS2011 -00046 P [�2/ 1 ? /T / a:1Seifen -- f, y 42.94 �� L• $ 220.82 Total: $- 220.82 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 202562 DHOWSE 06/21/2011 $- 220.82 Payor: Wyatt Fire Protection Inc. • Total Payments: $ - 220.82 Balance Due: $220.82 • • • Page 1 of 1 CITY OF TIGARD RECEIPT V 3 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 T[GARC� Receipt Number: 182156 - 04/14/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID FPS2011 -00046 Permit Fee - RES 2300000 -43104 $246.45 FPS2011 -00046 12% State Surcharge - Building 1003100 -24001 $29.57 FPS2011 -00046 Info Process /Archiving - Lg Sheet (over 2300000 -43135 $2.00 11x17) FPS2011 -00046 Info Process /Archiving - Sm Sheet (up to 2300000 -43135 $12.00 11x17) Total: $ 290.02 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 15552 DADAMSKI 04/14/2011 $290.02 Payor: Wyatt Fire Protection Inc Total Payments: $290.02 Balance Due: $0.00 • • • • Page 1 of 1 all e Community Development TIGARD Request for Permit Action 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 ❑ Contractor (sE City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) L) e f Pko r E e j / Mailing Address: 9 0 9 5 l c u Q46( --}H -, City/State /Zip: ' ' 4'2. D(2 q72-3 Phone No.: 1 5 - b5 (D q - 4 2Facd PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): I , CANCEL PERMIT APPLICATION. VO t ►1 • REFUND PERMIT FEES (attach . receipt, if available). ) • INVOICE FOR FEES DUE (attach case fee schedule and explain below). 72i/4' ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: /1°5 AD! / — 400 c lf D Site Address or Parcel #: ( 2(1;77 Aw 1 - folk or 1.4 sat Cr. Project Name: A , i rs &p, ? Subdivision Name: /9-Q.L rJ(o' TU,3 *aTs 443 Lot #: 5 EXPLANATION: -- Fm r ` DLL C t3e. 4 e Pcn- 1 H- r ■ori -cvo61 Signature: Date: Gj 4) // Print Name: _ i/5/61 f L i i1 ' 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 t. QERIMPW Rte to Bld• Admin: Dat- /NEM B Refund Processed: Date W// By,( L Invoice Processed: Date By Permit Canceled: Date A/ // By 42, Parcel Tag Added: Date By. Recei.t # % s Date /le 1/ Method , c Amount $ 0 290 u I: \Building \Forms \RegPemutAction.doc Rev 07/26/07 CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT "1 I COMMUNITY DEVELOPMENT Permit #: FPS2011 -00046 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/14/2011 Parcel: 2S109DA14000 Jurisdiction: TIGARD Site address: 12677 SW MOUNT VISTA CT Project: ARLINGTON HEIGHTS NO. 3, LOT 59 Subdivision: ARLINGTON HEIGHTS NO. 3 Lot: 59 Project Description: Installation of 13D fire sprinkler system for new residence. Contractor: WYATT FIRE PROTECTION INC. Owner: STONE BRIDGE HOMES 9095 SW BURNHAM 16869 SW 65TH AVE #505 TIGARD, OR 97223 LAKE OSWEGO, OR 97035 PHONE: 503 - 684 -2928 PHONE: 503 - 387 -7577 FAX: 503 - 684 -9657 FEES Description Date Amount Specifics: Permit Fee - RES 04/14/2011 $246.45 12% State Surcharge - Building 04/14/2011 $29.57 Type of Use: SF Info Process /Archiving - Lg Sheet (over 04/14/2011 $2.00 Class of Work: ALT Type of Const: VB 11x17) Occupancy Grp: R -3 Height: ft Info Process /Archiving - Sm Sheet (up to 04/14/2011 $12.00 Stories: 2 11x17) Commercial Sprinkler System: Sprinkler Required: Sprinkler Type: Standpipe Required: Hazard: Density: 0 Design Area: 0 K Factor: 0 Commercial Fire Alarm System: Fire Alarm Required: Alarm Type: Pull Station Required: Smoke Detectors Req: Battery Calcs Provided: Cut Sheets Required: Total $290.02 Valuations: Required Items and Reports (Conditions) Sprinkler Valuation: $0.00 Residential Square Footage: 2385 Fire Alarm Valuation: $0.00 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, o • - work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility ification Cent Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a .op of the rules or dire questions to OUN y mg 0 32.1987 or 1.800.332.2344. Iss ed By: Permittee Signature: ^ - Call 503.639.4175 by 7:00 a.m. for the next available inspec n date. This permit card shall be kept in a conspicuous place on the job site until ompletion of the project. Approved plans are required on the job site at the time of each inspection. • Permit A lication SiteitttinWes `itt Pg e -T tRECEIVED FOIL OFII( L USE ONLY g Received ��� /�� City of Tigard Re 114 Receiv Permit No.: ! - a 13125 S50 Hall n.2 Tigard, 39 Fax: OR 97223 - Plan B y ie cif © i Phone: 503.718.2439 Fax: 503.598.1960 A P Date/By: � �. /Other Permit No.: T I G A R D Inspection Line: 503.639.4175 CITY OFTIGARD Date Ready /By: y Q Juris: IZ1 See Page 2 for Internet: www.tigard or.gov Notified/Method: (el ti Supplemental Information TYPE OF WOR UIW,DING DIVISIO 4i.k � / #X, iR.., FEE* SCHEDULE I gPiew construction ❑ Demolition For special information use checklist. Description I Qty. I Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connecti • ) CATEGORY OF CONSTRUCTION SFR (1) bath 312.70 l- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 437.78 building SFR (3) bath 500.32 ❑ Accessory g ❑ Multi- family Each additional • : th/kitchen 25.1 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) P. _e 2 JOB SITE INFORMATION ' AN ) D LOCATION Site utilities: Job site address: /z6'7`! .„5/A/ 1© /)Il✓ / 1 'T e-- 1 Catch basin or area .. in 18.76 ' � Drywell, leach line, o trench drain 18.76 City/State /ZIP: ! .L /� V f 0/ ` n g 7 2--2-4-- Footing drain (no. Linea ft.: _) Page 2 Suite/bldg. /apt. no.: Project name: e4c-tr / m anufactured home utili ties 50.03 Cross street/directions to job site: x/4-37 Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: _) Page 2 Water service (no. linear ft.: _) I Page 2 Subdivision: I Lot no.: 59 Fixture or item: Tax map /parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 PAP i, /96S /(1‘49 / L f, �, ` l - , Dishwasher h e r her 25.02 V , c• t! !��� Dishwasher 25.02 .e _ 1 ), r Drinking fountain 25.02 S t Fr Ejectors /sump 25.02 m"'s.a 4 " �„Al.• . - ❑ TENANT Expansion tank 12.51 Name: Fixture /sewer cap 25.02 Floor drain/floor si ub 25.02 Address: Garbage disposal ` 25.02 City/State /ZIP: \ \\ Hose bib 25.02 Phone: ( ) Fax: ( ) Ice maker 12.51 4PPLICANT ❑ CONTACT PERSON Interceptor/gr ..e trap 25.02 Business name: WM 49-CTr2 Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: Roof drain (..mmercial) , .51 Address: Sink/basin/ +vatory 2' 02 City/State /ZIP: Solar unit (potable water) 62. , 4 Phone: ( ) Fax: : ( ) Tub /sho er /shower pan 12. E -mail: Urinal 25.0 CONTRACTOR Water loset 25.02 Wat. heater 37.52 Business name: i j � / 7 p f P O C-77 Wa • piping/DWV 56.29 1 Address: cif), 9 SJJ 13 wejviz�� S T Otter: 25.02 City/State/ZIP: -12(.47/4/2 /J ! 97zZ 3 Subtotal Phone: (5'03) t ii__- 29 g Fax: (503) bg4- - 94'5'7 Minimum permit fee: $72.50 CCB Lic.: ` 1°4-077 Plumbing Lic. no.: -_-----, Plan review (25% of permit fee) State surcharge (12% of permit fee) Authorized signature: /%7 �/"Z /„ e / TOTAL PERMIT FEE Print name: 604.5/,! %j `� f lJ Date: 4_ -5 -// This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. 1:\Building \Permits \PLMU- PermitApp.doc 10/01/09 440-46 16T( I 0 /t2 /COM /WEB)