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Permit u iECEI v 1 111 Q ' Community Development ,c I Request for Permit Action TIGARD CITY 0 OF 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 0 City Staff (check one) REFUND OR Name: 7J/ INVOICE TO: (Business or Individual) Mailing Address: VOID City /State /Zip: /gl4/0d' /- 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 PERMIT (do not cancel permit). Permit #: 1OR Ju V abos - oo `T Site Address or Parcel #: q 1-e0`d SL ( LLJ(u.3 C Project Name: �y ph fit♦ fl Trft 0-1+ PI-IL`/ VA Subdivision Name: •(/i Lot #: 1■ /1 _,_ I / ij EXPLANATION: 04) 1}T sr) / ,3 GJPOQ EE. Hsi ' yg -CO Signature: � Date: q I Ata 1 a8 Print Name: t- 11E. E. A-1)A-kSIS 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 ' 9-4 O; By Rte to Bldg Admin: Date By Refund Processed: Date Al By Invoice Processed: Date By Permit Canceled: Date //4/p B t" Parcel Tag Added: Date By Receipt # Date Method Amount $ I:\ Building \ Forms \Regl'ermitAction.doc Rev 07/26/07 Building Permit Application Residential FOR OFFICE USE ONLY City of Tigard a Dat : / Recei ANA 21 Permit No / , / »CO p n III o Ng • 13125 SW Hall Blvd., Tigard, OR 97223 Plan Re Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit: I - I GA R D Inspection Line: 503.639.4175 Date Ready/13y: r�r B See Page 2 for Internet: www.tigard- or.gov - ,..Notified/Method: / Supplemental Information • TYPE OF WORK, � '' • P;t t 1 � fit. •:�: '. ; • REQUIRED DATA: l- AND 2- FAMILY DWELLING ❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all V Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. 4 1- and 2-family dwelling Valuation: $ cz y g ❑ Commercial /industrial 7� ❑ Accessory building ❑ Multi - family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: • JOB SITE INFORMATION AND LOCATION Total number of floors: site address: g St W f � i I ( V i . e L 6.% New dwelling area: $�� square feet City /State /ZIP: r(j o 0 12 4 .7 L_ L Garage/carport area: square feet Suite/bldg. /apt. no.: ( y Project name: 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 (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. 0 d Cll I L'� .3 q 9 Q ' ., Valuation: $ �J► l V Existing building area: square feet New building area: square feet V PROPERTY OWNER ❑ TENANT Number of stories: Name: /2 - 6 , 1 4 V i ef C- it6 K� et Type of construction: Address: 96 o ' (.., 0 I I( o eI, Occupancy groups: City /State /ZIP: ' , e • ri 6 9 / '3 Existing: Phone: ( ) Fax: ( ) New: ❑ APPLICANT ❑ CONTACT PERSON r NOTICE Business name: 0 r� j 0 ' ✓ /d a'Lu h L (- All contractors and subcontractors are required to be Contact name: net t ' ` .� kt l no I/ak V licensed with the Oregon Construction Contractors Board �� /t `0 / under ORS 701 and may be required to be licensed in the Address: Cam /,, a 3 57� jurisdiction in which work is being performed. If the City/State/ZIP: /' '' r� r 1 R 7 or applicant is exempt from licensing, the following reasons © 9 `7 0 apply: Phone:ij j i , "lfq 2_ c r I Fax:: ( ) E-mail: J Z r 1 e . L. v (: tir e ho rvLeg' L� < e , # ;1'7 CO CTOR Business name: ) BUILDING PERMIT FEES* Address: . a 0AN e.._ Gt 4 i. (Please refer to fee schedule) Structural plan review fee (or deposit): e; ',?/ 5 .. c9 City /State /ZIP: Phone: ( ) F : ( ) FLS plan review fee (if applicable): 'e"---- CCB lie.: l 7 r �r 1 ' Total fees due upon application: d / .5 . Amount received: Authorized signature: This permit application expires if a permit is not obtained I ,�� within 180 days after it has been accepted as complete. / Print name; 1 f / Date: If • Fee methodology set by Tri -County Building Industry ✓ Service Board. I: \Building \Permits\BUP -RES PermitApp.doc 11/6/07 440- 4613T(1 I /02 /COM/WEB)