Permit •
Building Permit Application la,th '
Fire Protection System V 1' I FOR OFFICE tiSi ONLY
of Ti and (--.., Received
g �� l� . . DateB : ° • fiyl Permit No � / ... 1— i
° 13125 SW Hall Blvd., Tigard,OR 972 %3 \ _ 1 . Plan Review
1 C Phone: 503.718 2439 Fax: 503.59.1960`' ® `10 DateB : Other Permit. �L
I' 1 c. n It a Inspection Line: 503.639.4175 lie ' Date Ready/By tune ®See Page 2 for
Internet' www.tigard- or.gov S , P •;,, � ,; , Notified/Method 7=Ce Supplemental Information
TYPE OF WO - REQUIRED DATA: 1- AND 2- FAMILY DWELLING
Permit fees* e based on the value of the work performed.
❑ New construction ❑Demolition f• p
Indicate the value (rounded to the nearest dollar) of all
ddition /alteration /replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1- and 2- family dwelling �Commercial/industrial
Valuation: $
❑ Accessory building ❑ Multi - family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: G g3U 50 \g� New dwelling area: square feet
City /State /ZIP: _ ^ Q � Garage /carport area: square feet
Suite/bldg. /apt. no.: ( �t Project name: (,I v ( � �j -� Covered porch area square feet
Cross street/directions to job site: � " � Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: Permit fees' are based on the value of the work performed.
Tax map /parcel no.: Indicate the value ( rotnded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indicated on this application.
!`P S 7 5),/..., ^ ll' 1 „ Valuation: $ (33 - 09
Existing building area square feet
New building area: square feet
❑ PROPERTY OWNER I ❑ TENANT Number of stories:
Name:
OA aar” y dA \\ o Type of construction:
Address: L g 30 S.-, `Bw ,219 Occupancy groups:
City /State /ZIP: �,ry. i ,,, i' • g:
Existin
1
Phone: ( ) Fax: ( ) New:
APPLICANT ❑ CONTACT PERSON NOTICE
Business name: At 11 q l0 1 i fi Str „J rrY All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: .7 3 0 Kt. ( ., a ,, e 1, - jurisdiction in which work is being performed. If the
City /State /ZIP: - -P0, cQ /'7 Z 3 2 applicant is exempt from licensing, the following reasons
l� apply:
■
Phone: ( / ) q 7 1 2 . — LOC, Fax:. (5 ) 2 3 1... ..7s5.1
E-mail: L� ,(list' - A Cl ( - sow-4 , e -,
CONTRACTOR BUILDING PERMIT FEES*
(Please refer to tee schedule)
Business name: A l 14 . /`{ f 5E y
Address: � Neil, I Permit fee:
City /State /ZIP: —t„ i a_ 77 '3 .� State surcharge (12% (40% permit fee):
7
L ( Z FLS plan review (40 /o ofpermit fee):
Phone: (c5) 972 — C( () to I Fax: (5'03 )— Z'3) - ?cr./ (Due upon application.)
CCB lic.: 6 q (/ &G Total permit fees: AG , )--
Authorized signature: � Amount received:
p This permit application expires if a permit is not obtained
�
Print name: - 41 I Date: 0q/2 Amount
�/ � within 180 days after it has been accepted as complete.
• Fee methodology set by Tri- County Building Industry
Service Board.
I \ Building\PermiWFPS- PermitAppdoe 02/01/2011 440-4613T(11/02/COM/WEB)
II
, 1 ,
J L G A Rq
City of Tigard
October 18, 2012
Allied Fire & Security
530 NE Couch St.
Portland, OR 97232
Re: Permit No. FPS2011 -00112
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 6830 SW Bonita Rd.
Project Name: Clowns Unlimited
Job No.:
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $192.11.
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 $ .
Comrnent(s): Property owner installed fire sprinkler system instead of fire alarm
system. Refund 80% of plan review and permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
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: Allied Fire & Security DATE: 10/2/2012
530 NE Couch St
Portland, OR 97232 REQUESTED BY: Dianna Howse
DEB
TRANSACTION INFORMATION:
Receipt #: 183963 Case #: FPS2011 -00112
Date: 9/20/2011 Address /Parcel: 6830 SW Bonita Rd
Pay Method: CreditCard Project Name: Clowns Unlimited
EXPLANATION: Property owner installed fire sprinkler system instead of fire alarm system. Refund 80%
of plan review fee.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Plan Review Fee 230- 0000 -43108 $46.48
/ 7 ASo - o000 93/0 y //6,/9
l z % .5 T S u , e c i f 4 t a . . E - E - /cue - t000 - 2V O / /3,99
!i✓Fz►
/ 6ss ozje -C1o00 - 1 /3/. /S -5 t)
TOTAL REFUND: 4' $4
APPROVALS: ' /9.F2
If under $5,000 Professional Staff rA6.1i
If under $12,500 Division Manager l'UL—
If under $25,500 Department Manager 7i/ c
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONL
Case Refund Processed: I Date: /V/6/4,2-- J By:
1• \Budding \ Refunds \RcfundRcqucst doc x 09 /01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
i m 1 Request Permit Action
T l C; A It n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor VOID
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Fr City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ALL, 9.1) ACE. a. 5ECU el
Mailing Address: 530 N €. C.ot .
City/State /Zip: PD 2Tt,F} ►J1 62. q7 -5 �•
Phone No.: FIS. 3 - q "? - q ( 3(p
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: F 5 &O 1 1 - 00 11 2
Site Address or Parcel #: (otg 30 tA) — t no eTf} -R-1) Project Name: CLOUD rJ s U. tJ L.1 H , T E t
Subdivision Name: Lot #:
EXPLANATION: Ati2i5/ pt,JtJt.Q, INie i ft (.L. ***N 1q� met oIi,t --
Y'o1 -1 tt35rtf9-r of t%1 2e_ ALA&H. Vv lb PW-i,I— Pep_ s b'•
O t.t or P • - 1x64.11 of 2 •
Signature: I I Date: l a$ J
Print Name: I A (
Refund Policy
1. The Director or Building Official may authonze 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 pnor 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 LS
Rte to S s Admire: Date ' rglimunpyli Rte to Bld• Admin: Dated lb ® : �giLVIII h
Refund Processed: Date AI B 1, P- Invoice Processed: Date B 5P, i
Permit Canceled: Date igiffSffin B .f" . - Parcel Tag Added: Date By }L'
Receipt # Date Method Amount $ // '`
1: \ Building \ Forms \RegPemutAcuon.doc Rev 05/25/2012 Y4 7
r r J
City of Tigard: Fire Protection Permit Checklist
Page 2 - Supplemental Information
Describe work to be done:
1.) ❑ New 2.) M dification to sprinkler heads only:
❑ Addition 1 -10 heads: No plan review required.
❑ Alteration ❑ 11+ heads: Plan review required.
❑ Repair
Number of sprinkler heads:
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet ❑ Dry
Additional Standpipes
Information: Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: I $
C.) Fire Alarm
Submittal shall Battery Calculations Yes
include: Individual Component es
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $
FLS Plan Review (40% of permit fee): $
TOTAL: $
Plan review requires a completed application and three (3) sets of plans at submittal.
Plan review fees are required at submittal.
I•\ Building \ Permits \FPS- PerrutApp.doc 02/01/2011 2