Permit IN CITY OF TIGARD 1 VIS 1'D SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT I g(A fi I Permit #: SWR2011 -00120
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/09/2011
Parcel: 2S110DCO2200
Jurisdiction: Tigard
Site address: 15570 SW PACIFIC HWY
Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2
Project Description: .1 EDU increase. 8/24/11, revised, capping additional fixtures, now has a credit of .3 EDU's.
Contractor: Owner: TRC MM LLC
5973 AVENIDA ENCINAS STE 300
CARLSBAD, CA 92008
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 08/09/2011 $450.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: -.3
Total $450.00
Required Items and Reports (Conditions)
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. Those . -s - - set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC by c. ing 503.232.' 98 1.800.332.2344.
Issued By. /4i i � Permittee signature •-
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
u CITY OF TIGARD SEWER CONNECTION PERMIT
1,
COMMUNITY DEVELOPMENT Permit #: SWR2011 -00120
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/09/2011
Parcel: 2S110DCO2200
Jurisdiction: Tigard
Site address: 15570 SW PACIFIC HWY
Project: Safeway Subdivision: 1997 -016 PARTITION PLAT Lot: 2
Project Description: .1 EDU increase.
Contractor: Owner: TRC MM LLC
5973 AVENIDA ENCINAS STE 300
CARLSBAD, CA 92008
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 08/09/2011 $450.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .1
Total $450.00
Required Items and Reports (Conditions)
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. se rules . - set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OUNC y calli g 503.232. •8 •r .8':.332.2344.
Issue By: / / l / Permittee Signature `. ±�'
EL /`it i l. ■ .. _ � / / _ 'i , ir / !� t
Call 503.639.4175 by 7:00 a.m. for the next available inspec • • a e.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
-
City of Tigard
October 20, 2011
Tampani Plumbing
Attn: Carl F Homola
PO Box 2350
.. Battle Ground, WA 98604
Re: Permit No. SWR2011 -00120
Dear Mr. Homola:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15570 SW Pacific Hwy
Project Name: Safeway
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $450.00.
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): Applicant changed scope of work by capping (3) fixtures resulting in an
EDU credit. Refund 100% of sewer connection fee.
If you have any questions please contact me at 503.718.2430.
Sincerely,
-
A
Dianna Howse
Building Division Services Supervisor
Enc.
1:\ Buildin tefundsy 6st9Wntittili PaIncs gatrdpiikegon 97223 m 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard - or.gov
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 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: Tampani Plumbing DATE: 10/20/2011
Attn: Carl F Homola
PO Box 2350 REQUESTED BY: Dianna Howse
Battle Ground, WA 98604 Debbie Adamski
TRANSACTION INFORMATION:
Receipt #: 183604 Case #: SWR2011 -00120
Date: 8/9/2011 Address /Parcel: 15570 SW Pacific Hwy
Pay Method: CreditCard Project Name: Safeway
EXPLANATION: Applicant changed scope of work by capping (3) fixtures resulting in an EDU credit.
Refund 100% of sewer connection fee.
REFUND INFORMATION:
Fee Description From Receipt : Revenue,Account No. • Refund:
Example: Building Permit Fee Example:: 2300000 - 43104 .$_Ainount,
Sewer Connection Fee 500 - 0000 -25500 $450.00
TOTAL REFUND: $450.00
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager I)/Aj kk)
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ON ��?/
Case Refund Processed: I Date: I /e!/ -C // I By: I
I:\ Building \Refunds\ RcfundRcqucst.doc x 09 /01/2010
CITY OF TIGARD RECEIPT
44
g 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 184289 - 10/20/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2011 - 00120 s 6 -ct' e=72._ 6 e /n'C - C rlc. ..5d o - &Y co - o2s G 0 $ 450.00
Total: $- 450.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 600174 DHOWSE 10/20/2011 $- 450.00
Payor: Carl F Homola - Tapani Plumbing
Total Payments: $ - 450.00
Balance Due: $450.00
•
•
Page 1 of 1
11111 CITY OF TIGARD
V
� g . _ 1 3125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
TIGARD C
Receipt Number: 183604 - 08/09/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2011 -00120 Sewer Connection Fee 500 - 0000 - 25500 $450.00
Total: $450.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 600174 DADAMSKI 08/09/2011 $450.00
• Payor: Carl F Homola - Tapani Plumbing
Total Payments: $450.00
Balance Due: $0.00
•
Page 1 of 1
/ .
•
__,
I _,
Community Development
Request for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW l la11 Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name: Carl F Homola - Tampani Plumbing
INVOICE TO: (Business or Individual)
Mailing Address: PO Box 2350
City /State /Zip: Battle Ground WA 98604
Phone No.: • 360 - 687 -3983
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): \ t e IF
IL
8 CANCEL PERMIT APPLICATION. r�: /Ztl`l/
® 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 #: SWR2011 -00120
Site Address or Parcel #: 15570 SW Pacific Hwy
Project Name: Safeway
Subdivision Name: Lot #:
EXPLANATION: Contractor added (3) capped fixtures to scope of work resulting in
credits rather than additional EDU charges. -
Signature:
K.JULL, . C2C6_44t_xa 8/24/11
--- 175e - bbie 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 usc application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land usc 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 Adtnin: Date crainmamm Rte to Bldg ,Amin: Date , Zei ASII B //.
Refund Processed: Dateje 2J, By Invoice Processed: Date By
Permit Canceled: Date /c� By. .. 'arcel Tag Added: Date By
Receipt # Date • Method Amount $
I:\ Building \Forms \RegPemutAction.doc Rev 04/26/2011
•
Accumulative Sewer Tally
Mil Tenant Name: Safeway ** *REVISED 8/24/11 * ** SWR # 2011 -00120
•, ', Site Address: 15570 SW Pacific Hwy PLM # 2011 -00254
. 1;G 1RD.
• Parcel #: 2S110DCO2200 • .
Fixture Value Previous Previous Crcdits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptisery/ Font 4 0 0 0 0 0
Bath: - Tub /Shower 4 0 • 0 0 0 0
Jacuzzi /Whirlpool 4 0 0 0 0 0
•
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 • 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 • • 0 0 0 • Eye Wash 1 0 0 0 0 0
Hoor Drain /Sink: - 2 inch 2 • 0 2 4 0 -2 -4
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 • 0 0 0
- Car Wash 6 0 • 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 HP) 16 • 0 - 0 • 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 I-IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 • 0 • 0 0 0
Shower: - Gang (per head) 1 0 0 0 0 0 • - Stall 2 0 0 • 0 0 0
Sink:
- Lav /Bar - Non -Food Related 2 0 1 2 1 2 0 0
- Bradley 5 0 0 0 0 0
- C:om /Sere /Util - Food Related 3 0 • 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 • 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 • 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 _ 3 6 1 2 _ -2 -4
Current Fixture Value -4 divided by 16 = -0.3 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -4 divided by 16 = -0.3 over (under) $ (1,350.00)
Eater F.f1I ChangtHere -0.3 .--�
Notes ** *REVISED 8/24/11, CAPPING (3) FIXTURES. NOW HAS CREDIT'S OF -.3 T�.DU'S * **
Authorized Name /Signature: Debbie Adamski • _
Date: • . 8/9/2011
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
1:\ Building \Sewer T ally \SewerTallySheet- 4500.xls 07/01/11
IN ,,,,, Accumulative Sewer Tally
Tenant Name: Safeway SWR # 2011 -00120
Site Address: 15570 SW Pacific Hwy PLM # 2011 -00254
1x Parcel #: 2S110DCO2200
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Baptisery/Font 4 0 0 0 0 0
Bath: - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
1?ye Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0
Garbage Disposal:
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 III') 32 0 0 0 0 0
- Industrial (over 5 IIP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower: - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink:
- Lay/Bar - Non -Food Related 2 0 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Com /Sery /Util - Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 1 _ 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = $4,500.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 450.00
Enter EDU Change Here 0.1
Notes:
Authorized Name /Signature: Debbie Adamski Date: 8/9/2011
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
1: \ Building \Sewer Tally \Sewer I'allyShcct- 4500.xls 07/01/11