Permit ■
City of Tigard • COMMUNITY DEVELOPMENT DEPARTM ® ' 0
, . g Request Permit Action .
T G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ;Cit 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 (1):
CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
p INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: PO t.L.pA0 / 9 - OO, 74 (
Site Address or Parcel #: l i ( 55 6o 14.4-4-L__ IrL h ) I Lot-r5 L(l, q .a Lis - 44i
Project Name: .:-r. Z - tn t f.. AP6- 2-T7 A JT
Subdivision Name: Lot #:
EXPLANATION: L O 0 , 0 , �6 P€L t T - iPL e e1.4 —E.l i ,J i_ 2kt2- •
-f...f__ BPS 2.43 t3 -0000 3 •
( i_ P4Y 1`i /9-LA C 6-D Y x2.41.15 rf.2.►2f 7, Tv "RS
Signature: 1 Date: 01(4 13
Print Name: E I:56 I 0+Dvd=t-M 5 I.,-, 1
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ` Ate I B ___, Rte to Bld: Admin: Date-200M B`ti j"
Refund Processed: Date / - „ -Ay ,r-, Invoice Processed: Date By
Permit Canceled: Date 2 /2p% By J — Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \ReqPermitAction.doc Rev 05/25/2012
' °mit Application
RECEIVED _
[ Tigard DE FOR OFFICE USE ONLY
C 2 6 2012 Received
�W Hall Blvd., Tigard, OR 97223 Date /B : a -' 11 J- cf Permit No 1i l ig -o 3
re: 503.718.2439 Fax: 503.598.19�ITM r ►
^t� Plan Review
.spection Line: 503.639.4175 B t ILDI N G IS Date /B : Other Permit �Dao/a Dpad,
Internet: www.tigard- or.gov ulJ 11Yf DIVISION Date Ready /By:
fV Notified/Method:'i / , ® See Page 2 for
I w Supplemental Information
TYPE OF WORK 01.
New construction �._ j REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
® Addition/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
Job site address: 11155 SW Hall Blvd Total number of floors:
City/State /ZIP: Tigard, Oregon 97223 New dwelling area: square feet
Suite/bldg. /apt. no Garage /carport area: square feet
Project name: St James Apartments
Cross street/directions to job site: Covered porch area: square feet
Deck area: square feet
��� (,i S . Other structure area: square feet
Subdivision: REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
DES =S OF WORK equipment, materials, labor, overhead, and the profit for the
install 13R fire sprinkler system , n 4 units th t had fire damage work indicated on this application.
�- Valuation: $$7,520.00
Existing building area: square feet
❑ PROPERTY OWNER New building area: square feet
❑ TENANT Number of stories:
Address: Type of construction:
Occupancy groups:
Phone: ( ) CM11111111111.10 1111211111111111111111111111111111111111
® APPLICANT ® CONTACT PERSON
Business name: Western States Fire Protection Co. BUILDING PERMIT FEES*
Please re er to ee schedule
Contact name: Darrell Fluit Structural plan review fee (or deposit): IIMIIIIIIII
Address: 13896 Fir Street, Suite B
FLS plan review fee (if applicable):
City /State /ZIP: Oregon City, OR 97045
Total fees due upon application:
Phone: (503) 657 -5155 OD
Fax: : (503) 657 -5182 Amount received:
E -mail: darrell.fluit @wsfp.us 09. PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
CONTRACTOR Commercial and residential prescriptive installation of
Business name: Western States Fire Protection Co. roof -top mounted Photovoltaic Solar Panel System.
Submit two (2) sets of roof plan with connection details
Address: 13896 Fir Street, Suite B and fire department access, along with the 2010 Oregon
City/State /ZIP: Oregon City, OR 97045 Solar Installation Srecia! Code checklist.
Permit fee (includes plan review
Phone: (503) 657 -5155 and administrative fees : $1 80.00
Fax: (503) 657 -5182
CCB lic.: 104570 State surcharge (12% of permit fee):
$21.60
Authorized signature: / • Total fee due upon application: $201.60
' This permit application expires if a permit is not obtained
Print name: Darrell Fluit within 180 days after it has been accepted as complete.
Date: 12/24/12 ■ Fee methodology set by Tri- County Building Industry
/
(:\Building \Permits \BUP -COM PermitApp.doc 02/24/2011 Service Board.
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