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Permit
� ',, CITY OF TIGARD MASTER PERMIT I COMMUNITY DEVELOPMENT Permit #: MST2011 -00138 • 13125 SW Ha ll Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/17/2011 TIGARD g Parcel: 2S102DC01900 Jurisdiction: Tigard Site address: 9300 SW EDGEWOOD ST Subdivision: Lot: Project: Simmons Project Description: 1,772 sq foot addition. BUILDING ' Floor Areas Required Setbacks Required Stories: 1 Bedrooms: 2 First: 1772 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 13.5 Bathrooms: 1 Second: 0 sf Garage: 0 sf Front: 20 Smoke Dwelling Units: 1 Third: 0 sf Right: 5 Detectors: Yes Total: 1772 sf Value: $215,000.00 Rear: 15 PLUMBING Sinks: 1 Water Closets: 1 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 2 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 100 Drains: 0 Tubs /Showers: 2 Garbage Disp: 1 Water Heaters: 1 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 1 Hose Bib: 1 Backwater Value: 2 Other Fixtures: 0 Drywell- Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types - Air Conditioning: N Vent Fans: 1 Clothes Dryers: 0 Natural Gas Heat Pump: N Hoods: 1 Other Units: 0 Furn <100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 3 Furn > =100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc /Feeders Branch Circuits 1000 sf or less: 0 0 -200 amp: 0 0 -200 amp: 0 W/ Svc or Fdr: 0 Ea add'I 500 sf: 0 201 -400 amp: 0 201 -400 amp: 0 W/O Svc /Fdr: 5 Mfd Home /Feeder /Svc: 0 401 -600 amp: 0 401 -600 amp: 0 601 -1000 amp: 0 601 +amp- 1000v: 0 1000 +amp /volt: 0 ELECTRICAL - RESTRICTED ENERGY SF Residential Audio & Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing. N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ADD SF VB R -3 1772 Owner: Contractor: SIMMONS, STEVEN CRAIG & JOELLE L OWNER Required Items and Reports (Conditions) 9300 SW EDGEWOOD ST 1 Ersn Cntrl 503 - 681 - 4444 TIGARD, OR 97223 PHONE: PHONE: FAX: Total Fees: $6,163.26 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 iss ce, • if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notificatio Cen - Those rules are set forth in OAR 952 - 001 -0010 through • a : 952- 001 -0090. You may obtain : u es or ect questions to OUNC by calling 50 42.1' : or 800.332.2344. Issued By ■Ille ._- . !� �% 111 `er - - - ignature: Call s .6 , y 7:00 a.m. for the next available inspection date. This permit card sha b- -pt 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. Building Permit Application �� (f ' .-.� ► C L, t m, s: . . 9 Residential � ,�,� FOR OFFICE USE ONLY o City of Tigard � R eceived Permit No.: 1.11, DateB . ] LJ- -(,tSG a ° 13125 SW Hall Blvd., Tigard,OR 97 3 `\ Q� Plan Review y is 2. Phone: 503.718.2439 Fax: 503.598.1960 ∎ GG � G �� c J� Date /B I Other Permit: TI G A IZ D Inspection Line: 503.639 6 4 i) Date Ready : y: ® See Page 2 for Internet: www.tigard- or.goV V ` � ifi et S 5 � hod: (( %� Supplemental Information TYPE OF WORK Am REQUIRE DATA:1- AND 2- FAMILY DWELLING ❑ 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 CATEGORY OF CONSTRUCTION work indicated on this application. Valuation: $ ''7(� /'y') 12r1- and 2-family dwelling ❑ CommerciaUindustrial j� -"—�� • ❑ Accessory building ❑ Multi- family Number of bedrooms: 2 r ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: 1 Job site address: 1 SOO (.,,, G aoe t.,. r Si- . New dwelling area: 1 square feet 1 City /State /ZIP: Tifr- — OIL. q 7 ait 3 Garage /carport area: square feet Suite/bldg. /apt. no.: Project name: _5 %.10 n 0 f Covered porch area 240 square feet Cross street/directions to job site: Deck area: square feet © ry ... r . Other structure area: square feet I ��/1 REQUIRED DATA: COMMERCIAL -USE CHECKLIST Subdivision: I Lot no.: Permit fees* are based on the value of the work performed. Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. pa d 41‘a-s^ Valuation: $ Existing building area square feet New building area: square feet a PROPERTY OWNER ❑ TENANT Number of stories: Name: C t. o,�. Stew. ,,, yv 5 Type of construction: Address: ..S0.- YN A. L 6.-5 A.. b v v f - Occupancy groups: City /State /ZIP: Existing: Phone: ( ) Fax: ( ) New: ❑ APPLICANT a CONTACT PERSON BUILDING PERMIT FEES* (Please refer.lo fee schedule) Business name: Structural plan review fee (or deposit): 11, t. ot74 e): 7 Contact name: , q o y‘ 5 Address: rA , t% IA FLS p review f ee (if applicable): *- IN P a O b 0 V c Total fees due upon application: / v 7 . a,1 City /State /ZIP: i Phone: (y) 5 �. i.4 — 3 L b t. Fax:: ( ) Amount received: 03 E -mail: S i r•. re,,, w• S el a , n 3 6 r m wn [ a-S 4- • to .€ 4-- PHOTOVOLTAIC,SOLAR PANEL SYSTEM FEES* CONTRACTOR Commercial and residential prescriptive installation of , roof -top mounted PhotoVoltaic Solar Panel System. Business name: Ir�Oyv�G Pt.. C4— Submit two (2) sets of roof plan with connection details and fire department access, along with the 2010 Oregon Address: Solar Installation Specially Code checklist. City /State /ZIP: Permit Fee (includes plan review $180.00 and administrative fees): Phone: ( ) Fax: ( ) State surcharge (12% of permit fee): $21.60 CCB lic.: Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained / - within 180 days after it has been accepted as complete. Print name: �4e �-e 6 At �. w.. 0, 6 S Date: 11 2- 7 1 2d l) * Fee methodology set by Tri- County Building Industry Service Board. I:\ Building \Permits\BUP - RESPermitApp.doc 02/24/2011 440- 4613T(11/02 /COM/WEB) Building Permit Application Checklist ' One- and Two- Family Dwelling -FOR OFFICE USE ONLY lig City of Tigard Received Permit No.: ° II 13125 SW H all Blvd., Tigard,OR 97223 Date/By: II : Phone: 503.718.2439 Fax: 503.598.1960 Associated permits. TIGARD 24- Hour Inspection Line: 503.639.4175 ❑ Electrical ❑Plumbing ❑ Mechanical Internet: www.tigard- or.gov • 0 Other: THE FOLLOWING ITEMS. ARE REQUIRED FOR PLAN REVIEW Yes No - N/A I Land use actions completed. See jurisdiction criteria for concurrent reviews. ❑ ❑ ❑ 2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. ❑ ❑ ❑ 3 Verification of approved plat/lot. ❑ ❑ ❑ 4 Fire district approval required. Name of district: . ❑ ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . ❑ ❑ ❑ 6 Sewer permit. ❑ ❑ ❑ 7 Water district approval. . ❑ ❑ ❑ 8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ ❑ 9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑ basin protection, etc. 10 3 Complete sets of legible plans. Must be drawn to scale, showing conformance to applicable local and state ❑ ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if copyright violations exist. . 11 Site /plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ ❑ there is more than a 4 -ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements and driveway; footprint of structure (including decks); location of wells/septic systems; utility locations; direction indicator; lot area; building coverage area; percentage of coverage; impervious area; existing structures on site; and . surface drainage. 12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑ and location. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, ❑ ❑ ❑ furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc. 14 Cross section(s) and details. Show all framing- member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑ floor, wall construction, roof construction. More than one cross section may be required to clearly portray . construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings and foundation, stairs, fireplace construction, thermal insulation, etc. 15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. ❑ ❑ ❑ Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope. Full -size sheet addendums showing foundation elevations with cross references are acceptable. 16 Wall bracing (prescriptive path) and /or lateral analysis plans. Must indicate details and locations; for non- ❑ ❑ , ❑ prescriptive path analysis provide specifications and calculations to engineering standards. 17 Floor /roof framing. Provide plans for all floors /roof assemblies, indicating member sizing, spacing, and bearing ❑ ❑ ❑ locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered ❑ ❑ ❑ systems, see item 22, "Engineer's calculations." 19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑ over 10 feet long and /or any beam/joist carrying a non - uniform load. 20 . Manufactured floor /roof truss design details. ❑ ❑ ❑ 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas - piping schematic is required . ❑ ❑ ❑ for four or more appliances. 22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be stamped by an engineer or • ❑ ❑ ❑ architect licensed in Ore:on and shall be shown to be applicable to the •ro'ect under review. JURISDICTIONAL SPECIFICS 23 Three (3) site plans are required for Item 11 above. Site plans must be 8-1/2".x 11" or 11" x 17 ". ❑ 0. ❑ 24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. • ❑ ❑ ' ❑ 25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. ❑ ❑ ❑ 26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document.. ❑ ❑ ❑ 27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑ 28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ ❑ ❑ Street Tree List. 29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations, driplines, ❑ ❑ ❑ and protection measures must be drawn to scale and must include the project arborist's signature of approval. 30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ ❑ including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings on a lot of record approved prior to September 9, 1995. 1:\ Building \Permits\BUP- RESPermitApp.doc 02/24/2011 440- 4613T(11/02 /COM/WEB) . r Mechanical Permit Application FOR OFFICE USE ONLY III City of Tigard Received Date/By: a Permit No.: .-- I/4/ ' 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review 1 • Phone: 503.718.2439 Fax: 503.598.19-1 .$ Date/By: Other Permit. T I GA R D Ins Line: 503.639.4175 .A/15"\i, Date Ready/By: Juris: El See Page 2 for Internet: www.tigard- or.gov 6 Notified/Method: Supplemental Information �� 2A�1u AcY TYPE OF WORK 1� GV' COMMERCIAL FEE* SCHEDULE - USE CHECKLIST C Mechanical permit fees* are based on the value of the work ❑ New construction Z. Addition/alteration/r ent performed. Indicate the value (rounded to the nearest dollar) of all ❑ Demolition ❑ Other: �w�' • mechanical materials, equipment, labor, overhead, and profit. Value: $ CATEGORY OF CONSTRUCTION RESIDENTIAL EQUIPMENT / SYSTEMS FEES* V 1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building For special information use checklist. ❑ Multi - family ❑ Master builder ❑ Other: Description Qty. Ea. Total JOB SITE INFORMATION AND LOCATION Heating/cooling: Air conditioning Job site address: (requires site plan showing placement) A 46.75 g3oo 5 &) two d Furnace 100,000 BTU (ducts/vents) A 46.75 7'J_- City /State /ZIP: rl Ge r ci. D R 9 7 2 3 Furnace 100,000+ BTU (ducts /vents) 54.91 Suite/bldg./apt. . ect name: • Heat pump no. Project v ` l 0,1 �� S (requires site plan showing placement) 61.06 Cross street/directions to job site: Duct work / 23.32 7 Hydronic hot water system 23.32 0 IM d "'e Residential boiler (radiator or hydronic) 23.32 Unit heaters (fuel -type, not electric), in -wall, in -duct, suspended, etc. 46.75 Subdivision: Lot no.: Flue /vent for any of above 23.32 Other: 23.32 Tax map /parcel no.: Other fuel appliances: DESCRIPTION OF 'WORK Water heater 1 23.32 -- }- Gas fireplace 33.39 P ct c I / t D A Flue vent for water heater or gas fireplace 23.32 Log lighter (gas) 23.32 Wood/pellet stove 33.39 Wood fireplace /insert 23.32 PROPERTY OWNER ❑ TENANT Chimney /liner /flue /vent 23.32 ig) Other: 23.32 Name: C rat �i )Y1 Al D As Environmental exhaust and ventilation: Address: .? /' S io P Range hood/other kitchen equipment 33.39 City /State /ZIP: 1 . cf- D IT 7 cl a 3 Clothes dryer exhaust 33.39 Single -duct exhaust (bathrooms, Phone: (503 6 �t - 3 h G - 0 % Fax: ( ) toilet compartments, utility rooms) / 23.32 . ❑ APPLICANT LI CONTACT PERSON Attic /crawlspace fans 23.32 Business name: / Other: 23.32 C./ l�(2.L \ S/ tit Hit. 0 N C Fuel piping: Contact name: 6 a s 4 60 a £ $14.15 for first four; $4.03 for each additional Address: Furnace, etc. 9 14 t /'j Gas heat pump City /State /ZIP: Wall /suspended/unit heater Phone: ( ) Fax: : ( ) Water heater Fireplace E -mail: Range CONTRACTOR Barbecue Fl Clothes dryer (gas) Business name: .0 � M e vtv a 2 Other: Address: MECHANICAL PERMIT FEES* City /State /ZIP: Subtotal ' *6t.s Phone: ( ) Fax: ( ) Minimum permit fee ($90.00) Plan review (25% of permit fee) CCB lie.: State surcharge (12% of permit fee) V6 TOTAL PERMIT FEE J 4 � , 6 • Authorized si nature: This permit application expires if a permit is not obtained within 180 g .+yy._. -r 7� days after it has been accepted as complete. Print name: 3.4G fh e, aA* w.r►. „_,. g ! Date: 1 / p - , v )1 * Fee methodology set by Tri- County Building Industry Service Board � s , i:\Building\Permits\MEC- PermitApp.doc 09/09/1 440 -4617T (11 /02/COM/WEB) Mechanical Permit Application - City of Tigard Page 2 - Supplemental Information Commercial & Multi- Family Fee Schedule: Total Valuation: Permit Fee: $0.00 to $500.00 Minimum fee $69.06 $500.01 to $5,000.00 $69.06 for the first $500.00 and $3.07 for each additional $100.00 or fraction thereof, to and including $5,000.00. $5,000.01 to $10,000.00 $207.21 for the first $5,000.00 and $2.81 for each additional $100.00 or fraction thereof, to and including $10,000.00. $10,000.01 to $50,000.00 $347.71 for the first $10,000.00 and $2.54 for each additional $100.00 or fraction thereof, to and including $50,000.00. $50,000.01 to $100,000.00 $1,363.71 for the first $50,000.00 and $2.49 for each additional $100.00 or fraction thereof, to and including $100,000.00. $100,000.01 and up $2,608.71 for the first $100,000.00 and $2.92 for each additional $100.00 or fraction thereof. Note: All new commercial buildings require 2 sets of plans. • I:\Building \Permits \MEC- PermitApp.doc 09/09/10 2 . PlumBing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard Received �i,/ Date/By: Permit No.: O (J / / d /. Ci 13125 SW Hall Blvd., Tigard, OR 97 4 _ - C I /1 Plan Review 1 rI C _ Phone: 503.718.2439 Fax: 503.598' ',A Q11 Date/By: Other Permit No.: T t G A R D Inspection Line: 503.639.4175 ` Date Ready/By: luris. ® See Page 2 for Internet: www.tigard- or.gov `U1_ /,� • N y otified/Method: Supplemental Information TYPE OF WORK ® 11J1 FEE* SCHEDULE ❑ New construction ❑ De WI. i i AQ I For special information use checklist `11 Description I Qty. Ea. I Total ® Addition/alteration/replacement ❑ Of: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (1) bath 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 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND e w , AND LOCATION Site utilities: Job site address: 3 co S �J G L occi l . T Catch basin or area drain 18.76 G dal, Drywell, leach line, or trench drain 18.76 City /State /ZIP: o ' I tF A C' 0 12 ! 7 dl, 3 Footing drain (no. linear ft.: _) Page 2 Suite/bldg. /apt. no.: CJ Project name: ,3t tM 0 N f Manufactured home utilities 50.03 Cross street/directions to job site: Manholes 18.76 Rain drain connector 18.76 O INN r,... C w Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: WO Page 2 6215A-- Water service (no. linear ft.: ) Page 2 Subdivision: Lot no.: Fixture or item: Tax map /parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve Z 12 Clothes washer 25.02 / ' j J1 A, )1 Dishwasher 25.02 Drinking fountain 25.02 Ejectors /sump 25.02 0 PROPERTY OWNER 1 ❑ TENANT Expansion tank 12.51 Name: Fixture /sewer cap 25.02 Ark, Floor drain/floor sink/hub 25.02 Address: m �- /'r t9 v 'e Garbage disposal 25.02 Zr""c�z__ City/State /ZIP: Hose bib i l 25.02 ?tOz Phone: ( ) Fax: ( ) Ice maker 1 12.51 124S1 ❑ APPLICANT Er CONTACT PERSON' Interceptor /grease trap 25.02 Business name: Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: (,,, yy` C- !.(.- b 0 V e 5 Roof drain (commercial) 12.51 Address: Sink/basin/lavatory 25.02 7 _ City /State /ZIP: Solar units (potable water) 62.54 Phone: (5p ) JCa sl - 3/ f $ 4, Fax: : ( ) Tub /shower /shower pan ?-- 12.51 2.6,02.. E -mail: -g t r.. s". 0 o S c/ 5 Urinal 25.02 art �' Gc9w�tG -S�-. Nt CONTRACTOR Water closet / 25.02 Z642- Water heater 1 37.52 37 - Business name: Water piping/DWV 56.29 Address: G. y„ 1 { lrs X b 0 v e Other: 25.02 _ City /State /ZIP: Subtotal °3 t 0,T3 Phone: (5-e3) 5) y - 3 Ji g S Fax: ( ) Minimum permit fee: $72.50 , Plan review (25% of permit fee) CCB Lic.: ) Plumbing Lic. no.: State surcharge (12% of permit fee) 7 7 E r Authorized signature: O r y - TOTAL PERMIT FEE 3 50 !± c - b Print name: /J Y Date: This permit application expires if a permit is not obtained within 180 days S� e.ren t�Fgr ( f rH B h 5 /Q1 7) %� 11 after it has been accepted as complete. (J *Fee methodology set by Tri -County Building Industry Service Board. 1:\ Building \Permits\PLMU - PermitApp.doc 10/01/09 440- 4616T(10 /02/COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information • Fee Schedule: Residential'Fire Suppression Systems: Site Utilities Qty. Fee'(ea) Total Square Footage: Permit Fee: Footing drain - l' 100' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600. $169.69 3,601 to 7,200 $233.20 Sewer - 1st 100' 62.54 7,201 and greater $327.54 Sewer - each additional 100' 37.52 Water Service - 1st 100' 62.54 Medical Gas Systems: Water Service - each additional 100' 37.52 Valuation: Permit Fee: Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to and including $10,000.00. Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge - 1/2 hour) and including $25,000.00. , Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) . each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees Quantity by Fixture Type Plan Review for Plumbing Installations Fixture Type for Replace/ Plan review is required for any of the following. Performed: Capped Added Relocate ew q y g' Baptistry/Font Please check all that apply. Bath Tub /Shower ❑ Any new commercial building with water service 2" and - Jacuzzi /Whirlpool greater, except systems designed and stamped by licensed Car Wash -Each Stall engineer. -Drive Thru ❑ New exterior plumbing site utilities for any complex structure Cuspidor/Water Aspirator as defined in OAR918- 780 -0040. • Dishwasher - Commercial ❑ Medical gas and vacuum systems for health care facilities. - Domestic ❑ Any multipurpose fire sprinkler system. Drinking Fountain ❑ Any complex structure as defined in OAR918- 780 -0040. Eye Wash Floor Drain/sink - 2" Submit 2 sets of plans with any of the above. 4 .Isometric or Riser Diagram Car Wash Drain ❑ Isometric or riser diagram is required for new buildings Garbage - Domestic - non - food g ram s re q g Disposal - Domestic - food related that meet the qualifications above. - Commercial -food related - Industrial -food related • Ice Mach./Refrig. Drains Oil Separator (Gas Station) Comments regar fixture work: Rec. Vehicle Dump Station Shower -Gang -Stall SinkfLav - Non -food related _ - Bradley - Commercial -food related - Service .. • Swimming Pool Filter *Note: If the fixture work under this permit results in an Washer - Clothes Water Extractor increase of sewer EDUs, a sewer permit will be issued and Water Closet- Toilet fees assessed for the sewer increase must be paid before the Urinal • plumbing permit can be issued. Other Fixtures: • l:\ Building \Permits\PLMF - PermitApp.doc 02/24/2011 2 • Electrical Permit Application �� FOR OFFICE USE ONLY City of Tigard R eceived Permit No.: y f p� S � Date/By: D1. Q 2 C ) �34 ° 13125 SW Hall Blvd., Tigard, OR 97,, �{{ Q� Plan Review : ' a ` Phone: 503.718.2439 Fax: 503..v . I �j( - .. Date/By Other Permit: T t G A R D Inspection Line: 503 �l ` O � Date Ready/By: Juris: El See Page 2 for Internet: www.tigard- or.gov \� V ��v �. C ,� Notified/Method: Supplemental Information TYPE OF WORK { . \ 6 PLAN REVIEW ❑ New construction B'Addition/alteration& pent Please check all that apply (submit 2 sets of plans w /items checked below): ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: $ where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural 1- and 2- family dwelling ❑ Commercial/industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi- family ❑ Master builder ❑ Other: ['Fire pump. ❑ Installation of 75 KVA or JOB SITE INFORMATION AND LOCATION ❑ Emergency system. larger separately derived system. ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ", Job no.: Job site address: �3 pD ,St,,,.) Lc e w � q A s+ • Six or or more r R occupancy. ❑ Six or more residential units. ❑ Recreational vehicle parks. q ❑ Health -care facilities. ❑ Supply voltage for more than Clty /State /ZIP: T I w' 8 9)Z ` 1 ,2 a .3 ❑ Hazardous locations. 600 volts nominal. Suite /bldg. /apt. no.: Project name: ,_51` M °� 5 ❑ Service or feeder 600 amps or more. t�. FEE SCHEDULE Cross street/directions to job site: Description I Qty. I Fee. I Total New residential single- or multi - family dwelling unit. Q yv■ G— C A. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 168.54 4 • Tax map/parcel no.: Ea. add'I 500 sq. ft. or portion 33.92 1 Limited energy, residential sq. 75.00 2 DESCRIPTION OF WORK ( with above 9 ) ft. Limited energy, multi - family 1 residential (with above sq. ft.) 75.00 2 Services or feeders installation, alteration, and/or relocation 200 amps or less 100.70 2 [PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 Name: e rek.t _Si' r. e . - 601 amps to 1,000 amps 301.04 2 Address: l3 CO S J6.t 1..0 t9e 5 t• Over 1,000 amps or volts 552.26 2 City/State/ZIP: �7— Temporary services or feeders installation, alteration, and /or Ci I t te.4-a B R- q I J relocation Phone: (j19) ) * / . 3y 0 f Fax: ( ) 200 amps or less 59.36 1 O� 201 amps to 400 amps 125.08 2 Owner installation: This installation is being made on property that I own which is not 401 amps to 599 amps 168.54 2 intended for sale, lease, it o xchange, according to ORS 447, 449, 670, and 701. Branch circuits — new, alteration, or extension, per panel Owner signature: . .....---Y Date: T'p'T/ 1 1 A. Fee for branch circuits with ❑ APPLICANT p'CONTACT PERSON above service or feeder fee 7.42 2 each branch circuit Business name: B. Fee for branch circuits without t . service or feeder fee, first Contact name: r^ �� e branch circuit I 56.18 5-0 , r 2 Each add'I branch circuit if 7.42 (Di 2 Address: Miscellaneous (service or feeder not included) City /State /ZIP: Each manufactured or modular 67.84 2 dwelling, service and/or feeder Phone: ( ) Fax: : ( ) Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 E - mail: Sign or outline lighting 67.84 2 CONTRACTOR Signal circuit(s) or limited energy Business name: �, tom A S A 1 k) e panel, alteration, or extension. Page 2 2 Each additional inspection over allowable in any of the above Address: Additional inspection (I hr min) 66.25/ hr City/State /ZIP: Investigation (1 hr min) 66.25/ hr Industrial plant (1 hr min) 78.18/ hr Phone: ( ) Fax: ( ) Inspections for which no fee is 90.00 / hr specifically listed (% hr min) CCB Lie.: Electrical Lie.: Suprv. Lie.: ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: r5" Plan review (25% of permit fee): Print name: C r i ,w m ►^s C� (� 4 Date: ]/a 0 State surcharge (12% of permit fee): (t!? r3 U Authorized signature: TOTAL PERMIT FEE: 1 This permit application expires if a permit is not obtained within 180 Print name: L - ' /� "1 days after it has been accepted as complete. J-�,�, / _..n. 1 '- Date: .-- '7 • Number of inspections allowed per permit. • I: \Building\Permits\ELC- PermitApp.doc 07/01/10 440- 4615T(I 1/05 /COM/WEB Electrical Permit Application - City of Tigard { Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined $75.00 Check Type of Work Involved: ❑ Audio and Stereo Systems* ❑ Burglar Alarm ❑ Garage Door Opener* ❑ Heating, Ventilation and Air Conditioning System* n Vacuum Systems* ❑ Other: COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918- 309 -0000) Check Type of Work Involved: ❑ Audio and Stereo Systems n Boiler Controls n Clock Systems ❑ Data Telecommunication Installation ❑ Fire Alarm Installation n HVAC ❑ Instrumentation ❑ Intercom and Paging Systems ❑ Landscape Irrigation Control* ❑ Medical ❑ Nurse Calls n Outdoor Landscape Lighting* ❑ Protective Signaling ❑ Other Total number of commercial systems: *No licenses are required. Licenses are required for all other installations 1:\ Building \Permits\ELC - PermitApp.doc 07/01 /10 " Building Division Development Code Provision Review TIGARD Residential Projects Building Permit No: (119W/ — OD( CWS Service Provider Letter Received: • ' Yes ❑ No ❑'"N /A ❑ 6 - ( a 'Prw fz(.e.9 " "er 8 Routed Plans: Original Plan Submittal Date: ( /' •J, pt Revision Submittal Date: ❑ Site Plan Only 2nd Revision Submittal Date: ❑ Site Plan Only To the Applicant: Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies to the Building Division. Only checked (✓) items are approved. Items not approved and those listed in the notes must be revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed above each section. Staff: please check items along left only if approved. / Planning Review (contact S/ Ut 1 at 503 - 718 - ` or 5./LL r(J.er @tigard- or.gov) Land Use Case No. - Name t ' Zoning 1 2 4.5 Er Setbacks: • Front C Rear l <- Side C Street Side / S Garage ' JZI Maximum Building Height 3 Actual Building Height Visual Clearance Easements Sensitive Lands Type: N I f°4 Notes: Original Plan: Approved Er' Not Approved ❑ Date: 3731 / Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: Engineering Review (contact Mike White at 503 - 718 -2464 or MikeW @tigard - or.gov) Actual Slope: Notes: 4 Original Plan: Approved Not Approved ❑ Date: :" Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: (Review Continues on Page 2) Page 1 of 2 City Arborist Review (contact Todd Prager at 503 - 718 -2700 or todd @tigard - or.gov) 0 Street Trees (V /f1 i 4 Protected Trees /.I I \ Notes: Alo+ ass oc; ci I a a u.tt — h o p d -j re s . Original Plan: Approved I Not Approved ❑ Date: $ - '{ (/ Revision 1: Approved ❑ Not Approved ❑ Date: Revision 2: Approved ❑ Not Approved ❑ Date: Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @tigard - or.gov) ❑ Conditions of Approval Prior to Issuance of Building Permit Notes : Original Plan: Date Sent to Applicant: Revision 1: Date Sent to Applicant Revision 2: Date Sent to Applicant Okay to Issue Permit: Yes Q/ N Date Routed to Building: Page 2 of 2 joy - (� jAUG 1 Z-0!/ • 1 e Clean Water Services File Number CleanWate Services I l - 0 ` 1 Z`) Sensitive Area Pre - Screening Site Assessment r 1. Jurisdiction: / ma 2. Property infortio( 1S234AB01400) 3. Owner Inf mation Tax lot ID(s): Name: LCc0., J i .. A% m 0 r1 S Company: o Address: /SW S Lai F,C5 t Wed ei .SQL - Site Address: 300 S w eC e St City, State, Zip: re p a 7 . .3 City, State, Zip: Tire re!. QJ q 7�o� 3 Phone /Fax: -S. IS - y o2'(- 3 y ag Nearest Cross Street: Brvt,0 r'4 E -Mail: Si u►n,m Q n$ Lien S 6. Ce»1 W U eT 4. Development Activity (check all that apply 6. Applicant information Addition to Single Family Residence L room • eck, garage) Name: Lot Line Adjustment El Minor Land Partition Gompany: Pi El Residential Condominium El Commercial Condominium Address: � . 0 Residential Subdivision 0 Commercial Subdivision © Single Lot Commercial pulti Lot Commercial City, State, Zip: Other / 7 Phone/Fax: E -Mail: 6. Will the project involve any off -site work? l0Yes p.No f Unknown Location and description of off-site work • 7. Additional comments or information that may be needed to understand your project This application does NOT replace Grading and Erosion Control Permits, Connection Permits, Building Permits, Site Development Permits, DEQ 1200•C Permit or other permits as Issued by the Department of Environmental Quality, Department of State Lands and /or Department of the Army COE, All required permits and approvals must be obtained and completed under applicable local, state, and federal law. By signing this form, the Owner or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at all reasonable times for the purpose of Inspecting project site conditions and gathering Information related to the project site. I certify that tam familiar with the information contained in this document, and to the best of my knowledge and belief, this Information is true, complete, and accurate. Print/Type Name e C. 61' IAN, i » S Print/Type Title Signature r Date g/101.970)) FOR DISTRICT USE O ❑ Sensitive areas potentially exist on site or within 200' of the site, THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OFA ' SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural Resources Assessment Report may also be required. Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200' of the site. This Sensitive Area Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.02,1. All required permits and • approvals must be obtained and completed under applicable local, State, and federal law. ❑ Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s) found near the site, This SensitiveArea Pre - Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered. This document will serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local, state and federal law. ❑ This Service Provider Letter is not valid unless CWS approved site plan(s) are attached. ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROVIDER,, TTER I$ REQU RE . Reviewed by iLCJ 4 Date /i`l /// we ., 2550 S H1l High da y H ill s b o ro, O 9 P hon e (503) 681 510 F (503) 681- 4439 ` V . cl o rg r tt P' I W' E Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical, and plumbing per mits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: S (St iv....r.o Name CCB# Expiration Date I will inform my general contractor that a II subcontractors who work on the structure must be licensed with the Construction Contractors Board. or I will be performing work on property I own, a residence that I reside in, or a residence that I w ill reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. S A e A1 e iN e cv ,` c7 it vw r".0 ,\S Print am of Permit Applicant 7/a 7/ t 1 Signature of Permit Applicant Date Permit #: r — e L,20 l j — (x) /3 g Address: 9600 ., ' ��._. ;, • - Oe 97 as 3 : :; :.�...., Issued by: 97T Date: 0/ 7 /( F This Copy for Permit Offices • MARK 55UE,REVSION DATE n 1 PRELIMINARY REVIEW SET 05/26/2011 * # * NOTICE ' � i� 2 FINAL REVIEW 6/25/2011 I J - 3 PERMIT SET "1/2"1/2011 INFORMATION CONTAINED HEREIN "`� 5 THE SOLE PROPERTY OF PRES- 1, J - �� I �� o � c � ' ICE T GAD DESIGNS. RI - !^ /` 7• /, J U L 2 9 2 1 S L LIGATION OTRANSMITTAL TRANSMTAL OF F M- ,SIo FORMATION CONTAINED HEREIN 5 X ✓ V & CA�e � EXPRESSLY FORBIDDEN WITHOUT PERM551O N OF PRESTITI GE CUSTOM „..•••• •-•••-......"' N i l® GAD DESIGNS. CITY r l t DESIGNER 5 NOT A LICENSED BUILDING G ®IV S ON ARCHITECT OR ENGINEER. THESE PLANS DO NOT NECESSARILY RE- �'� ELECT BUILDING CODE COMPLI- ANCE. CONSTRUCTION SHOULD IT NOT BE UNDERTAKEN WHOUT PROFESSIONAL ASSISTANCE. D 336' 0 ilfi_____ -- o \ -- -- -- -- -- .a o N 0 X 51' -S" q CI c, " o �� n M w 11---.. ., c '� E N�� + O 0 u '13 x EXISTING I PROPOSED o o - N . 1C ADDITION t RESIDENCE I ao 50. FT. a a c n ° Y 210' l" x 1518 SQ. FT. It CONCRETE I x'1,1i 1i ,:: }:::_° CD / A PATIO I r1:: �,� o cc I ) /04. i',.,-,:nt s, < �( f 1- " a "sxs�"r�' .�" E X to \ I } :,;, x° It � mw E Ir PROPOSED EXISTING DRIVEWA ...— 0 HEM ° t--- Zt ADDITION EXISTING t- - w `s 1,212 50. FT. • GARAGE v A �°` 520 SQ. FT. w to � X � ' . >R X,��Y.itKxxxxssYg °� W EXISTING ISLAND Q zo I`� O �0N _.._._ i= o ° tea° Ill t z `, ,,,EXISTING DRIVEWAY O Q i i.___ _ _ , \ 1 33b' i v 2o I PROJECT NO.: PCCD- 001 -011 DATE: 01/21/2011 SCALE: AS SHONW S ITE PLAN ,, ( DESIGNED BY: TR 1 DRAWN BY TR SCALE = /� CHECKED BY: TR SCALE: 1 " - 20'-0" SHEET TITLE 1 13 m , SITE PLAN m 0 SHEET NO. Fri A-002 :".-1 r �• . TL GARD ' City of Tigard January 6, 2012 Steven C Simmons 9300 SW Edgewood St. Tigard, OR 97223 Re: Permit,No. MST2011 -00138 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 9300 SW Edgewood St. Project Name: Simmons Job No.: Refund Method: ❑ Check # in the amount of $ . ® Credit card "return" receipt in the amount of $4,276.72. 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 job was cancelled. Refund 100% of excise tax fees, 80% of permit fees and state surcharge. Retain all plan review fees as plan review was completed prior to request for cancellation of permit. If you have any questions please contact me at 503.718.2430. —I v° "' ice" Sincerely, �� ` �� Z a vow a �_'-`_ ,,,I) ..."(5.17-6.7.----- -----on -- :6. -----4 .a p yA m OS GD y . 731A Dianna Howse i G. Building Division Services Supervisor < o no 4. wa 4 '.01 N � 01 m A IT1 m W m T w m ■ Enc. _ = N m m N O. 10 ZI; Fa C�p� 7 .1 N .-i m «- CO .4 : \ Building \ Refunlal n�Et1'2ticklakt lakliafce1T'igaCd4 Q TTY Relay: 503.684.2772 • 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: Steven C. Simmons DATE: 1/4/2012 9300 SW Edgewood St. Tigard, OR 97223 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt #: 183684 Case #: MST2011 -00138 Date: 08/17/2011 Address /Parcel: 9300 SW Edgewood St. Pay Method: CreditCard Project Name: Simmons EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees. - - ' +?;.;.'T,=`e`� ��„; ^'e;d ° - ,xt. y :;z - - - ' -�'� .�`"� �'�' � i�.k.`_ = '�`. � ;�„'.,"�"- f'fs= .�r V:;t+' = #;- = t..u:;F;;�,s_v REF:UwN ONFORMATION M z V l aWAN: ,.�.�-WWV � `- ^ :; 3 � ��;r > %':s�:� -_ _ �°a��- r.-:ra^ ,�. ";.��'E ....3==re:.:.. - •ae:�r *-08,46-44,R, �<ta�a; �.�' :,��4 Ron ;;s -. . - 7Fee6DescnptionsErom Rece><pf�, �' ��^ VA n Na. Rgfund � '� �x � a �`,� ,� '� �+r i� �'3u -� 3 -� 3 �.atr s 6ExMA ;Biulding Pei i t Feex `' __ , l 'Exa le 2300000 43104 @ $ Ainounti Tig -Tual School Construction Excise Tax @ 100% 230 - 0000 -24102 $1,860.60 Metro Construction Excise Tax @ 100% 230- 0000 -24010 258.00 Erosion Control Permit Fee @ 80% 230- 0000 -22002 70.40 Building Permit Fee @ 80% 230- 0000 -43104 1,440.44 Electrical Permit Fee @ 80% 220- 0000 -43103 68.69 Mechanical Permit Fee @80% 230- 0000 -43102 104.70 Plumbing Permit Fee @ 80% 230- 0000 -43101 250.21 12% State Surcharge @ 80% 100- 0000 -24001 223.68 TOTAL REFUND: $4,276.72 APPROVALS: If under $5,000 Professional Staff , I, If under $12,500 Division Manager IAA It) O ,+.-)\■ If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board ' ,`I� g �ii,;,: ". , -,,ast a ; a .�;. : - - �' ' - - - - - - - - -,� �� � - - �" � `- '_'•e�"�is. .,S'.�� , .,- a�,i€n °.� , ~`_,'„ FQ. RTIDEMARKaSYS_TEMLADIVIINISTRAT IQN USE.,ONL Y�_. `�= l Case Refund Processed: Date: 6 /z_ B : Ma L:\ Building \Refunds \RefundRequcst.doc x 09/01/2010 CITY OF TIGARD RECEIPT I 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 •TIGARD / c FLIA7L Receipt Number: 185102 - 01/06/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID M ST2011 -00138 S i -C ,� " /7 C/ /E6 /E{ , L G % 6o4 g $- 4,276.72 Total: $- 4,276.72 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01530B DHOWSE 01/06/2012 $- 4,276.72 Payor: Steven Simmons Total Payments: $- 4,276.72 Balance Due: $4,276.72 Page 1 of 1 CITY OF TIGARD RECEIPT : II 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 183684 - 08/17/2011 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER , J PAID MST2011 -00138 Building Permit - Additions, Alterations, 230 - 0000 -43104 , ./j/0 , yy $1,800.55 Demolition MST2011 -00138 12% State Surcharge - Building 100- 0000 -24001 , 7 Z • P6 $216.07 MST2011 -00138 DC Provision Review, SF - Ping 100 - 0000 -43112 $65.00 MST2011 -00138 DC Provision Review, SF - LRP 100 - 0000 -43117 $10.00 MST2011 -00138 Info Process /Archiving - Lg Sheet (over 230 - 0000 -43135 $20.00 11x17) MST2011 -00138 Plan Review 230 - 0000 -43106 $98.15 MST2011 -00138 Info Process /Archiving - Sm Sheet (up to 230 - 0000 -43135 $24.50 11x17) MST2011 -00138 Metro Const. Excise Tax - Residential 230 - 0000 -24010 ..734 00 $258.00 Use MST2011 -00138 Tig -Tual School CET - Residential 230 - 0000 -24102 /f4 CT •60 $1,860.60 MST2011 -00138 Erosion Control 100- 0000 -22002 -20 • `1e $88.00 MST2011 -00138 Erosion Plan Review CWS 100- 0000 -22003 $28.60 MST2011 -00138 Erosion Plan Review COT 230 - 0000 -43107 $28.60 MST2011 -00138 Branch Circuits wo /Purchase Service or 220 - 0000 - 43103. 6 `I $85.86 Feeder MST2011 -00138 12% State Surcharge - Electrical 100- 0000 -24001 cf, 02) $10.30 MST2011 -00138 Furnaces < 100K BTU 230 - 0000 -43102 3 7. Ye $46.75 MST2011 -00138 Duct Work 230 - 0000 -43102 41 $23.32 MST2011 -00138 Water Heater 230- 0000 -43102 /d'.. ( 6' $23.32 MST2011 -00138 Single Duct Exhaust (Bathrooms, Toilet, 230 - 0000 -43102 /f, G' 6 $23.32 Utility Rooms) MST2011 -00138 Fuel Piping 230- 0000 -43102 /7, 32 $14.15 MST2011 -00138 12% State Surcharge - Mechanical 100- 0000 -24001 / • .5 $15.70 MST2011 -00138 Storm and Rain Drain 230 - 0000 -43101 ,..5?0 •O-.y $62.54 MST2011 -00138 Backwater Valve 230-0000-43101 - -.1.0.0- 2. $25.02 MST2011 -00138 Garbage Disposal 230 - 0000 -43101 .20 ' O 2 $25.02 MST2011 -00138 Hose Bib 230 - 0000 -43101 2-e • C $25.02 MST2011 -00138 Ice Maker 230 - 0000 -43101 io • 0/ $12.51 MST2011 -00138 Sink 230 - 0000 -43101 • e $25.02 MST2011 -00138 Lavatories 230 - 0000 -43101 " ©• Of $50.04 MST2011 -00138 Tub /Shower /Shower Pan 230 - 0000 -43101 - •0.Z $25.02 MST2011 -00138 - Water Closet -- 230- 0000 -43101 o.2e, . D .2 $25:02 MST2011 -00138 Water Heater 230 - 0000 -43101 .3c; , 11.2 $37.52 MST2011 -00138 12% State Surcharge - Plumbing 100- 0000 -24001 -.3O , V .2_ $37.53 Total: �a,6.72. $5,091.05 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01530B DADAMSKI 08/17/2011 $5,091.05 Payor: Steven Simmons Total Payments: $5,091.05 Balance Due: $0.00 Page 1 of 1 " ECU L.,..14 Community Development P NOV 2 3 2011 TIGARD Request for Permit Action CITY OF TIGARD J i . ' LAY' TO: CITY OF TIGARD Building Division Services Supervisor V 0 y,' 13125 SW Hall Blvd., Tigard, OR 97223 4//10 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov % /4 /off 47/' FROM: 21 Owner I Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: / INVOICE TO: (Business or IndividuaIndividual) 51 e rg rn , � ,• s vb. °✓1 Mailing Address: 1 3 QC , W �� eu..) 4- - City/State/Zip: 7 e,. c a O Q 7 7 a. 3 Phone No.: f Q g- 5 ;Z'-! ` 3 Li sh � PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): • CANCEL PERMIT APPLICATION. • REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: I t 1 . -CEO (s F j Site Address or Parcel #: C7 3d o $ L) C � e uplOd 64. Project Name: & ; d■A0 n S Subdivision Name: Lot #: EXPLANATION: O (NC f - -t 4'0 V\ C401 e (t r � G� s c Tr`n ncz5 Signature: -Se Date: t / A Si (g0l 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% 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 _ Refund Processed: Date //MEM B . Invoice Processed: Date B ' Permit Canceled: Date , /(, /� By -t 5� • . cel Tag Added: Date By AE-GP T I � t �' C. C..