PFI2013-00005 March 28, 2013 City of Tigard
Rob Flemmer
19990 SW Gassner
Beaverton, OR 97007
Re: Permit No. PFI2013-00005
Dear Mr. Flemmer:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10240 SW McDonald St.
Project Name: Sidewalk Repair
Job No.: N/A
Refund Method: ❑ Check# in the amount of$
® Credit card"return" receipt in the amount of$800.00.
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Work performed was on private property and not in right-of-way,
therefore refund 100% of application fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of Tigard
Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Requestfor Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Rob Flemmer DATE: 3/28/2013
19990 SW Gassner
Beaverton, OR 97007 REQUESTED BY: Dianna Howse
Mike White
TRANSACTION INFORMATION:
Receipt#: 190507 Case #: PFI2013-00005
Date: 3/6/2013 Address/Parcel: 10240 SW McDonald St.
Pay Method: CreditCard Project Name: Sidewalk Repair
EXPLANATION: Work performed was on private property and not in right-of-way. Refund 100%of
application fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Customer Deposit 100-0000-22000 $500.00
PFI Permit Fee 100-0000-43114 300.00
TOTAL REFUND: $800.00
APPROVALS: SIGN TURES DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: 3 � / B
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
C'C"
Request Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • wwwAijzarp,ov
TO: CITY OF TIGARD V
oBuilding Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 �/V
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name: � ^
INVOICE TO: (Business or Individual) W$ L€W1 Im
Mailing Address: q B w 6 A.. 55 NAIt„_
City/State/Zip: 071C. 41 -700 -7
Phone No.: 97 1 570 - 62- 37
PLEASE TAKE ACTION FOR THE ITEMS) 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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ZD 17 _ woos
Site Address or Parcel#: 162-40
2„40 l-'Pau+rh:!b 51
Project Name: p7walu 04! g44�x—
Subdivision Name: Lot #:
EXPLANATION: `Q 6,-19 .rJ A-LA. f ftS AAA Je4b5a>f5 � U-hrx- L
�5 &A.) PZ40A-M F'/zlor4-,r`f tib?" i tj R4%A). Twr. vcr*c.
Signature: kN Date:
Print Name: m j c-K Q-c<� LJ H jam.
Refund Poliev
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°/S 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 809/6 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 2-4 weeks for processing refunds.
FOR OFFICI--- USE ONLY
Rte to Sys Admin: Date B Rte t 3 dmin: Date M, / B
Refund Processed: Date 2- r / B Invoice Processed: Date B
Permit Canceled: Date 3 B Parcel Tag Added: Date B
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12013-00005
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/06/2013
Parcel: 2S111 BB01301
Jurisdiction: Tigard
Site address: 10240 SW MCDONALD ST
Subdivision: TIGARDVILLE HEIGHTS Lot: 9
Project: Driftwood/McDonald Sidewalk Repair
Project Description: Replace approximately 20'of sidewalk on McDonald at Driftwood.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/06/2013 $300.00
PHONE: Customer Deposit 03/06/2013 $500.00
Contractor: /
PHONE:
FAX:
V
\v�
Applicant:
ROB FLEMMER
19990 SW GASSNER )
BEAVERTON, OR 97007
PHONE: 971-570-8237 r�'
Total $800.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant
4w� �
Signature:
r
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 190607 - 03/06/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID.
PF12013-00005 Customer Deposit 100-0000-22000 $500.00
PF12013-00005. PFI Permit Fee 100-0000-43114 $300.00
Total: $800.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 14317B. TLEHRBACH 03/06/2013 $800A0 '
Payor: Rob Flemmer
Total Payments: $800.00
Balance Due: $0.00
Page 1 of 1
City of Tigard
Public Facility Improvement (PFI) Permit
General Information: SFOR STAFF USE ONLY
Property Address/Location(s): 1 Q 2A U SW lac.Do n oJJ _%. Case Nonn E UP,)—QowS
Receipt No.: «0 S07
r/ n Date: 3 6
*Applicant's Name: /'C •a0/Y/ll'��tC Application Accepted By:
Address: / d ��o �l��S//G'2 Revised 7/1/10 X300 4e+ X)gisuran[�
City/State: Zip:
Primary Contact: REQUIRED SUBMITTAL
Phone:
97! Fax: INFORMATION
Professional Engineered Plans are required
,r for:
Contractor's Name: /�leYc D"l�/''/�t' Q
• Street Widening
CCB# Expiration: • Subdivision Infrastructure
Address: /�D 'l(SS_0 �sv • blain utility line extension:
City/State: MI/ Sc nd zip:OR. 0 Storm Drain,Sanitary—Tigard
o, yy > 0 Water—Tigard Water Service Area
Phone: /��'S7�—O��J Fax: (includes Durham,King City and a
portion of unincorporated Washington
County)
Plans By:
**Note:See Engineered Plan
Address: Submittal Checklist attached.
City/State: Zip: For all other work:Submit scaled sketch of the
Phone: Fax: work to be done.(see attached minimum sketch
requirements and provided sketch area).
Description of work- p�,oirr e I:curpin\master\land use application\1311 app.docx
Estimated value of work(within the public right-of-way): $ 6b
Is work related to a LAND-USE DECISION? YES NO
If so,please specify(MLP,SDR,SUB,etc.) case#:
Is the work related to a BUILDING PERMIT? YES NO
If so,please specify(BUILDING PERMIT)case#:
*NOTE:Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for the work.
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 4
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement (PFI) Permit:
Part 1: All non-water system improvements
Engineer's estimate.X 5% (less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit.Fee = Part 1+ Part 2
PFI'Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• 'Sidewalk or driveway repair (less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
4 Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is$50.00 per address.
SAMPLE
Minimum Sketch Requirements
North Arrow Property Lines&Dimension 4 Slope of Property
Street& Street Name(s) 4 Existing Building,Structures 4 Utility&Street Light Poles:
J Proposed Work Existing Curb or Edge of Pavement 4 Trees
J Existing S/W or D/W Apron 4 Existing Utility Locations (sewer,water,storm)
City of Tigard 13125 SW Hall Blvd.;Tigard,OR 97223 1 503-718-2464 www.tigard-or.gov I Page 2 of 4
SAMPLE SKETCH:
Edge of Pavement
Ditch
Streetlight I —•—•—•—•---•— —r---
/ I °• Rain rerun
I I GttO o
dMe1weTine—
I -
I I Qj I
Existing House
I I ri I Existing 1
Driveway
�t I vi I
C� I �-
�I � 1
3 I '
a
I I
I CrI� 1
I � Existing Shop �
t J
Powerpole I
��► o o
I I 95' 1
I I -—
- -Wroperty[.ne----------
' I
Fire Hydrant(F H)
I � I
Scale: 'I"=30'
� � I
I � I
I
I I
� � I
Minimum Sketch Requirements (Put"n/a"if Not Applicable):
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(sewer,water,storm)
City of Tigard 1 13125 SAY'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 3 of 4
SKETCH AREA:,
0
City of Tigard 13125 SW Hall Blvd.,Tigard,,OR 97223 503-718-2464 www.tigard-or.gov Page 4 of 4