Permit � v
Community Development
Request for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall 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:
INVOICE TO: (Business or Individual)
V 0 1 AL_ Mailing Address:
/®� A � City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR P7Ct* FR PERMIT (do not cancel permit).
Permit #: Ase,c)1,90-e - 00/55 Oc 7
Site Address or Parcel #: 426/ 7 Si) e 07/44.41
Project Name: I 1ll)'V V ci /_ ^ " L v- lQ !
Subdivision Name: ! V F �` V L Lot #:
r
EXPLANATION: Inm t N CrroV`,
l/ /P/ r C4 *- ern /r Grt e ed O
S l'cclaooe -D 7 /9y .r.,2czo0, -Dopy?
Signature: Date: 5 ye)
Print Name: Eiccvude 1 cteltAv
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 retumed 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 7Ia B lr Rte to Bld: Admin: Date .5j0r®r" B -
Refund Processed: Date it/ . B Invoice Processed: Date B
Permit Canceled: Date AJ B E2 arcel Ta : Added: Date B
Receipt # Date ' Metho. Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
Accumulative Sewer Tally Parcel # 2S104AD -04500
Tenant Namei >t TUALATIN VALLEY FIRE AND RESCUE This SWR# SWR2008 - 00059
Site dress: 12617 WALNUT RD. This PI.M# PLM2008 - 00158
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 2 2 2 2
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 2 4 2 4
- 3 inch 5 0 0 3 15 3 15
- 4 inch 6 0 0 3 18 3 18
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 I -IP) 16 0 0 1 16 1 16
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 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 5 10 5 10
Sink - Bar /Lavatory 2 0 0 9 18 9 18
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 5 15 5 15
- Service 3 0 0 2 6 2 6
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 8 48 8 48
Urinal 6 0 0 2 12 2 12
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 43 170 43 170
Current Fixture Value 170 divided by 16 = 10.6 Current EDU 1 EDU = $ 2,800
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 170 divided by 16 = 10.6 over (under) 5 29,680.00
Enter EDU Change Here 10.6
Notes: '1'l -IESE TWO PERMITS WERE VOIDED AS PAYMENTS WERE MADE UNDER SWR2008 -00048 & PLM2008- 00194.
Authorized Name /Signature: BRANDEN TAGGART Date: 5/7/2008
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 \Sewer'f allyShect- 2008.xls 06/30/07