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Request for Permit Action $ 0
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TO: CITY OF TIGAR) C A 0��1)
Building Division Services Coordinator B
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Q City Staff ,
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) / A._
Mailing Address:
•
City/State /Zip:
Phone No.: •
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 #: ft- OkA004 -- X57
Site Address or Parcel #: t 1 ), - 7 LI y g) 000-74 '-> At -114 —
Project Name: y _AN) k
Subdivision Name: Lot #:
EXPLANATION: 14 b1I) 6 Y, X "17 d'i Lo# 0 1 4 PLA 60
ND v -t L 4. >t:5 Qu. kQ.c"ID .
Signature: i 1 •iL✓vv0_ 1Q-a Date: 9 15
Print Name: f-PDI )I4L ADf- 11-4514,‘
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 as received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date gig Q Rte•to • Admin: Date 9��6� B /7
Refund Processed: Date N ,9- By 'PM Invoice Processed: Date By
Permit Canceled: Date 9/� A/0O By i'� . ' ' arcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \forms \RegPermitAction.doc Rev 07/26/07
Accumulative Sewer Tally Parcel # 1s133ad1600
Tenant Name: Key Bank This SWR# 2009 - 00057
Site Address: 12744 North Dakota This PLM# 2009 - 00173
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s 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 1 1 1 1
Eye 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 Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 1 -IP) 16 0 0 0 0 0
- Commercial (to 5 1-IP) 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 - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 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 1 1 _ 1
Current Fixture Value 1 divided by 16 = 0.1 Current lIDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 1 divided by 16 = 0.1 over (under) $ 310.00
Enter EDU Change Here 0.1
Notes: 9/15/09, sewer permit voided as fixture was a replacement, not an additional fixture. Debbie Adamski
Authorized Name /Signature: Loraine Sellers Date: 6/30/2009
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.
I: \ Building\ Sewer Tally \SewerTallySheet- 3100.xls 06/19/08