Permit City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 •
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T I GARD
October 7, 2008
Apollo Drain & Rooter Service
2208 NW Birdsale Ave., #8
Gresham, OR 97030
Attn: Jamie Serbick
Re: Permit No. PLM2008 -00308 & SWR2008 -00111
Dear Ms. Serbick:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12785 SW Pacific Hwy
Project Name: Burgerville
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $540.12.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as job was given to another contractor. Refund 80% of
permit fees.
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If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Building\ Refunds \Administration \LtrRefund- CancelPermit.doc 01 /16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov . TTY Relay: 503.684.2772
City of Tigard
TIGARD Tidemark Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
. attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Apollo Drain & Rooter Service DATE: October 2, 2008
2208 NW Birdsdale Ave., #8
Gresham, OR 97030 REQUESTED BY: Dianna Howse
Attn: Jamie Serbick
TRANSACTION INFORMATION:
Receipt #: 2008 -2563 Case #: PLM2008 -00308 and
SWR2008 -00111
Date: 7/21/08 Address /Parcel: 12785 SW Pacific Hwy
Pay Method: CreditCard Project Name: Burgerville
EXPLANATION: Per applicant's request as job was given to another contractor. Refund 80% of permit
fees.
REFUND INFORMATION: '
Fee. Description From Receipt ' Revenue Account No Refund • Example: .[BUILD] Permit. Fee ;, . 'Example:, 245 0000 432000' - $ Amount ,
[PLUMB] Permit Fee 245- 0000 - 431000 $482.24
[TAX] 12% State Surcharge 100- 0000 - 207020 57.88
TOTAL REFUND: $540.12
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager
If under $22,500 Department Manager
If under $50,000 City Manager
. If over $50,000 Local Contract Review Board
• FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: I /1/d' / e I B I 4W—
I: \Building \Refunds \ RefundRequest.doc 05/23/07
' ' CITY OF TIGAR� 10I6I200
e 13 12; SW Tian Blvd. 1 1: 35:26f \ \I 4 .
",,, :i : : 'Tigard, OR 97223 503.639.4171
TIGRD
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Refund Receipt #: 27200800000000003466 jEij 7' r 4-L--
Date: 10/06/2008
Line Items:
Case No Tran Code Description Revenue .- account No Amount Paid
PLM2005 - 00305 Reversal - [PLUMB] Permit Fee 2 45 - 0000 - 431000 - (482.24)
PLM200S- 00308 Reversal - [TAX] 12% State Sur 100- 0000 - 207020 (57.88)
Line Item Total: ($540.12)
•
Refund:
Method Payer User ID Acct. /Check No. Approval No. Flow Received Amount Paid
Credit Reversal SCOTT BIRD - APOLLO DRAIN 05850D Fax (540.12)
& ROOTER
Refund Total: ($540.I2)
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:''': ; CITY OF TIGARD • 7
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i _ i,, 13125 SW Hall 131v�d. ;7:07PM .
Tigard, OR 97223 503.639.4171
is1GA
Receipt #: 27200800000000002563 6) X/6.7 /'1- - • .• • Date: 07/21/2008
Line Items: •
Case No Tran Circle Description Revenue Account No Amount Paid
PLM2008 - 00308 [PLUMB] Permit Fee 245- 0000 - 431000 602.80
• PLM2008 -00308 [TAX] 12% State Surcharge 100- 0000 - 207020 72.34
Line Item Total: $675.14
Payments:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
CreditCard SCOTT BIRD - APOLLO DRAIN DEB _ 05850D Fax 675.14
& ROOTER
Payment Total: $675.14
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..Rr.',,,,,31„ I'21,,. I of I
• Ciep.30. 2008 2:12PM No. 4536 P. 1
" Building Division RECEIVED
Request for Permit Action,
T I GARD.• S E P 3 0 2008
TO: CITY OF TIGAltD CITY OFTIGARD
BUILDING DIVISION
Permit System Admiinia • 13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718,2430 Fax 503 - 598.1960 www.tigard- or.gov
ROM: ❑ Owner ❑ Applicant At Contractor ❑ City Staff
(check one)
REFUND OR Name: . � ,) t.
INVOICE TO: (Dwinesr Or tndivid0al)
Mailing Address: ' +j; 7 • • , `-• _ ( , , t , . L. to 1P .
V 0 1 f /State /7�ip: ( , :1k . - 1 . I 7U� '�( ) —
D Ci
`d /2 /0 P Phone No.: G . 9X. , , C , ` -) \ _
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
_ 'M APPLICATION.
2. 1 i RT . • PERMIT I'ELES (attach receipt, if available),
• INVOICE FOR FEES DUE (attach case fee schedule and explain below).
D REMOVE CONTRACTOR FROM PERMIT (do not cancel peruut) Perron #: ?Lm 1 cr - 003L - co/i/
)
Site Address or Parcel #: 1 r • �� L .) J I,L ) l a; ,( . '( 1.
Project Name: Y l j(( j,i.. �' �` e k . � -
_
Subdi vision Name: Lot it:
EXPLANATION: f. 1,{ I I/ a I %1(') '7 („C , ,1 , CA' \ .%1 ti l_ Q C c.-� /�
( '�i,�_ =(� '7 _ b e lui--
- e,f. b P -ce 3 '1 .5w -- oo/38
Signature: (' -,_;--, ;')-1 c !:k_.. y.,t Date: l ._)C) 08 Print Mune: — </ i t', (. '')`' LI? ( (.i-
)teFiind Policy
I. The DIreccoe or Building Official my authorize the refund of
a) ony (ee which w enormously paid of collected.
b) not mo then 8C'% of the land use application ree when en application is withdrawn or canceled before any review effort hit been tar ndcd
c) not mom than 8O!k of the land use application fee for issued pcunits.
c) not more than 80/o of the building plan review fce when an applicadei la canceled hafoee any plan ceoiew effort by been expended.
tl) not more than 130°• o of the building permit fee for issued permits prior to any lttspt(tlon ecquesta.
2. Refunds will be tctvmed to the original Payee in the tame method in which payment was received. Plow a➢ow 1-2 weeks for processing refunds.
I' ONLY _
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Rte to S e Admix): Date 7 = ZIMI3!IP�, Rtc to Bid_ Admin: - . Date ' / J0;' B
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Refund Processed: Date /dAgrara %yM invoice Processed' Date ■
Permit Canceled: Dates /'• 2 O . B • -; �S I Parcnl Tag Added: Date _ _ B
Rect:i t Me—. - Date 0 2, �_ _ Arnourtt $
l: \awl• rg \ltotrns \RcgpermitAction.d R .-05/24/06
- Jel• 21. 2008 10:31AM mil 114------;‘,...4. r / i ( No. 2502 P. 2
' .r it •1i•vtid
Plumbtn �. � ��'W
•, , t # FOR OFFICE tISE ONLY
. uilding Fix �+ res
City of Tigard Received nn DSOS' 7 /. . 1A". ,• / /
I 11 u 13125 SW Hall Blvd., Tigard, 0� gl0 Plan Review piper Permit No.: t �� //
Phone: 503.639.4171 Fax: 503. 98.1960 �1 Dana
TIC A IL L7 Inspection Line: 503.639.4175 \ \ - rr Dal! Ready/By; � I Se
www
Internet: . tigard - or.gov � c1 � Notified/Method: 7 it /0 "Min. S Supplemental 3 - -• Information
. _ '. :: .::'
_.. _....',..:...... ...
..'• :..............:: :'..::....::_:.:.,'TYPE 0 ..ti ... .. . •�. . ::.: :: .77. .._ .... _ • : + S .. -.
■ << ' For s. eclat f ornlarlon use cllecklist
• ❑ New construction 1on Dcscri.non • s Ea. Total
F Addition/alteration/replacement ❑ Other. New 1- 2- family dwellings (includes 100 ft. for each utility connection)
...::..._...;.. •: _::.. ..;';_ =::, :GA'K')?ditiR`Y: OF GON1S'T[1U:C710N,; -...:. ; ::: = -: ::: ;:;:' : :': SFR (1) bath
❑ 1- and 2-family dwelling
yrCommercial/industrial SFR (2) bath 350.00
SFR (3) bath 399.00
[] Accessory building 0 Multi - family
• Each additional bath/kitchen 45.00
❑ Master builder ❑ Other: Firc sprinkler ( sq. ft.) Page 2
:;_;-; :- ' :- :.:;._:::: : :: :r013 SITE ,-Yly!<OR_, \fA`,1<?ION::1l1Yi? LO. CeCT.IO !f_: := __ ,':`•. : ' ;': : : ?`i: � 5itcntilltles
Job site address: 12_`7 - . J rati.�I.!.j l- r�,, Catch basin or area drain o' 16.60 i
City /State/ZIP: lr A 0 j ./`_ i • MM.. Drywcll, leach lint, or trench drain 16.60
Footing drain (no. linear ft.: ____) Page 2
Suite/bldg./apt. no.: Project name: ,ev, Manufactured home utilities 110.00
Cross street/directions to job site: Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear ft.: n/i, — Page 2 `- W
Storm sewer (no. linear ft.: Page 2
Lot no.: Water service (no. linear ft.: �) Page 2
Subdivision: Fixture or Item
Tax map /parcel no.: Absorption valve 16.60
. _ - - .. ...:'_. •- .' 1? SCR1 ]P 7<`xOP�T :;:Q>F:_'IV:g ;-: .�:: :;: :: -:� ='i� °r : � : : : _ ;;::: : :: = .-: ; : := BacWow premier Page
�� � • a s I h / B valve 1$ 16.60 � , �
�� • N /.�� P_l/Y1 �1/I 16.60
Clothes
1111M1111 r . A
_ - Drinking fountain Dishwasher
n n o
- -' - - ejectors /sump
_.: ':..... ... .... ... _:._..... ... 16.60
Name: Expansion tank ■. 16.60 rp /
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Address: 16.60 /
City /State/ZIP: . Floor dram/fl v ub # r•±. 16.60 /( • a
Garbage disposal MN 16.60 Phone: ( ) Fax: ( ) -' Hose bib 16.60 FR EA
s' :Y:' -; :: :,.:-: ::-' ;pERSOt�::: Ice maker Mill 16.60 MIA
1 d � ��M interceptor /grease trap 16.60
Contact name: I Medical gas (value: $ ) — Page 2
/1 r J . Jim . I � ��^
Address: `it / Primer �r♦ 16.60 �� U
Roof drain (commercial) 11.1. 16.60 —
Cily / State/ZIP: 1 r , , Irl 1 Sink/basinhavatory " 111a 16,60 WPM e j
Phone: ( •) 6111 /Op . 1 / 00 Fax:: ( ) Tub /shower /shower pan b 16.60 INN
E -mail: _ Urinal
R - : : _, ;. :::;` :. ' : . ::-::= : : ::: ° � ::::. � W t close( f/.ti A
1 60
Business name: j • - / � WRv • < i r , Water heater 16.60 Mina M
Ad dress: I /�' Other. rM � 4
■ �+ ! Subtotal i°
City/Slate/ZIP: Pirr4 .. fJ# j4 9 7' ,b Minimum , unit fee: $72,50 I oro
w F a x: (6� /' ' Residential backflow minimum permit fee: $36.25
ECIE Phone: 1 ) III . `•n Li r � � Plan review (25% of permit fee) •.i��r�i!'
i �� Plumbing Lie. no. - �73
State surcharge (12% of permit fee) ���',
Authorized signaiure� � / TOTAL PERMIT FEE Mi f'
Print name I e h ■. / G Dismal / / of This permit implication expires If a permit Is not obtalnc within
180 days after it has been acce pted as complete.
5-63--- � � —, *Fee tnetltodology set by Tri•County Building Industry Service 13a/
a 616T )
t: �HuildinglPUmlistpLMF- PtrroilAppA 17n7/06 J
r
. • ,. . Jul. 21. 2008 10:31AM No. 2502 P. 3
. :Plumbing Permit Ap licp A tion - City of Tigard •
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Fee ee :' :f a Foote ...e:.
...: f) I Sgt iar g Permi
::::;:. - �;.. :. -: - ...:.::.
•..Site :fi itl< es. ::::..: :. ::�_;: :::..._ ... - 0 $lu.00
-
Footing drain - 1°1100' 55.00 $115.00
46.40 - 2,001 to 3,600
Footing drain - each additional 100' 3,601 to 7,200 $220.00 —
Sewer 100' 55.00 7,201 and greater $309.00
Sewer - each additional 100' 46.40
Water Service. 1st 100' 55.00 Medical Gas S stems•
.. ::
Water Service • each additional 100' 46.40 _ V - .....''''
Perm><t F
55.00
Storm & Rain Drain 1st 100' $1.00 to $5.000.00 Minimum fee $72.50
Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.5 for $ e first $5,000.00
fraction an $1.520 for each
-.. .._... .... Feo 7 . Tot and
Q!Y: ..:.: ( ) :::`_,.... includin $]0.000.00.
F;tgture :or..Item:� _:. :: .,: :;= -�� :::: ::... :. = _... - ,.•� := _ .
Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for
each additional $100.00 or fraction thereof, to
Residential Backflow Prevention Device (minimum nd including $25,000.00.
Rain Drain, si ng permit fee $36.25) 27.55
Rain sile family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
each additional $100.00 or fraction thereof, to
Inspection of existing plumbing or and including $50,000.00.
specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $ L20 for
Subtotal; each additional $100.00 or fraction thereof.
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Commercial Fixture Work: ,_ _ : .Pli a ciffliim" -bit* Iiista at t ns:
Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following.
please indicate work performed by fixture. Failure to Please check all that apply.
* ❑ Any new commercial building with water service 2" and
accurately report . fixtures could result in increased sewer fees . greater, except systems designed and stamped by licensed
: : ::::, :: ` b�iYlure Work E ce erlbrmed::: . engineer. re
:Fixture rigs ) la p la s for any complex strut
erartous - Cipped . Aaded -1 14 Q New exterior plumbing site utilitic r an c m 1 ex to
Ba.tist /Font as defined in 0AR918- 780 -0040.
Bath -Tub/Shower ❑ Medical gas and vacuum systems for health care facilities.
•Jacuai!Whirlpool ❑ Any multipurpose fire sprinkler system.
Car Wash - Each Stall _ ❑ Any complex structure as defined in 0AR918 780.0040.
- Drive Thru
Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above.
Dishwasher - Commercial _ _
- Domestic :: ._Iometr>< or:aee ::::::.: ::::.••
Drinking Fount ain ,�� ` =1 Isometric or riser diagram is require for new buildings
E e Wash that meet the qualifications above.
Floor DreiNsinl 2"
3 „ r • oil_
- 4"
r____. Car Wash Drain ■ •
Oarbagc - Domestic Comments regarding fixture work:
Disposal - Commercial
_
- Industrial —
ice MachJRefri Drains
Oil Separator (Gas Station)
Rec. Vehicle Dump Station
Shower -Gang _ --
Stall
Sink Bar/) avatory 2 *Note; I([ the fixture work under this permit results in an
-C y -Comm increase of sewer EDUs, a sewer permit will be issued and
ommercial a 4 r
- Service 4 • • fees assessed for the sewer increase must be paid before the
Swimming Pool Filter _ plumbing permit can be issued.
Washer - Clothes
Water Extractor -
Water Closet • Tot -.
~ tinal
Other Fixtures:
sanity' P Kull** ** /u -J c,...4 I" e4•�•t
s avM