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Permit RECEIVED .. • . Community Development :1)11 SEP - 220[, TIGARD Request for Permit Action BUILDING DIVISION • 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) A V 0 1 D Mailing Address: ity /State /Zip: 06/6? Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM n PERMIT (do not cancel permit). Permit #: I' 1.._1" g — 0( . Site Address or Parcel #: / [ '&..„0 NCI r 'L ld-t.A.)y Project Name: A Led26P C-0 Subdivision Name: ( fr Lot #: -- EXPLANATION: Cl4-413(ct 0 r 1....1-t.), ��0 lQ,5c_S LA-JD �€ J —1.J . APPLY/N, 4-; - T is 1-i Signature: , 1. .A I 1 . . Date: 9410 o Print Name: -----¢ gPj I er. AID 6-146 (t 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date ' A p R R ys. iv Rte to Bldg Admin: Date / 4/p F. By '•%r Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date j /6 /C a By .7 7, - ' arcel Tag Added: Date By Receipt # Date Method Amount $ I:\ Building \Forms \ReqPermitAction.doc Rev 07/26/07 1yfiiding Permit Application Commercial �<t< } FOR OFFI USE O ,. ; i ONLY IN City of Tigard " \ . v'.-,,,-,--'. •-,..,' 1 ,... _ .. Da y 'Z O$ Permit No 13125 SW Hall Blvd., Tigard, O "� X23'''' y o �8 -OD C R Plan Review P hone: 503.639.4171 Fax: 503.598.196Q t , `j, Date/By. Other Permit: TIC A Iz D Inspection Line: 503.639.4175 3 , - , Dare Ready /By: j. ^ � ® See Page 2 for Internet: www.tigard or 1 , ?: ;: i ;'i , N / ,. < . 1 , V ,,' \ t C� Supplemental Information y r - r e.y, TYPE O ° ° �Q,•* .`' REQUIRED DATA: 1- AND 2- FAMILY DWELLING ❑ New construction 0 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. ❑ l- and 2- family dwelling Q Commercial /industrial Valuation: $ - ❑ Accessory building El Multi-family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: - Job site address: Il f-, ,,,,,_ L 1 ( �, 0 . LL t', J y `{ ° g area: square New dwelling feet City /State /ZIP: ' C, _ � • !� 2 - ' Garage/carport area: square feet Suite/bldg./apt. no.: Project name: p a 4 i ! l�' 0. Covered porch area: square feet - Cross street/directions to job site: Deck area: square feet Other structure area: square feet REQUIRED DATA: COMMERCW, -USE CHECKLIST - Subdivision: 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 equipment, materials, labor, overhead, and the profit for the • DESCRIPTION OF WORK work indicated on this application. i D Valuation: $ 57 SOO Existing building area: square feet New building area: square feet PROPERTY OWNER I ©• - TEN ANT Number of stories: 'Jame: /4/I . j e_ 4 e / $ - / ` r - f�j Type of construction: Address: 6 c . �' / Occupancy groups: City /State/ZIP: / j . r -[ (2 . e 72 Z / 4 /�- / _ Existing: phone: (SC3) j O _ f ' C �' Fax: ( ) New: G © CONTACT PERSON NOTICE Bus name:l 1�e° .a !�� ` !% "C , °2 4,ire nl i . .t, (.1.,,;.,:,c •h All contractors and subcontractors are required to be Contact name: licensed with the Oregon Construction Contractors Board 7 ` .t Y - �� t under ORS 701 and may be required to be licensed in the e. Address: �- Gt4( Lj C { ,. • ,, ju risdiction in which work is being performed. If the City/State/ZIP: applicant is exempt from licensing, the foljowing re s a Phone: / l . t: C.4 , '' apply: r1 P (S'c, )) 2_ C C�.• te a/ c - �' Fax: (5- z) S G. 5 / tc ✓ \° �, ma C 46 E -mail: /-ex-c: % u.t J CG�r1:7 6 \i` 0 Y`re CONTRACTOR IF (#1 � tt 0 i A, ` • B usiness name: x ii„.,_ [ c - - z/ � ' u % BUILDING PERMIT FEES* r p ilv v V Address: (Pleaa'erefertofeeschedule) V' - City /State/ZIP: Structural plan review fee (or deposit): / 7 phone: ( ) I Fax: ( ) FLS plan review fee (if applicable): l/ 9 i CCB lic.: / U `% Total fees due upon application: Authorized signature: 1 Amount received: , / 4 -/ . (.00 This permit application expires if a : ermit is not obtained print name: l ��p within 180 days after it has bee , ccepted as complete. tu-- ���G Date/ --- 0 r • Fee methodology set by Tri -County Building Industry rr Service Board • I -COM PermitApp.doc 2/23/07 440- 461 3T(11/02 /COM/WEB) 1 /