Permit r
City of Tigard, Oregon c 13125 SW Hall Blvd. ° Tigard, OR 97223 ,
Ii
•
November 6, 2009 L -_ __ .
KEC Electric, Inc.
761 SW Bailey Ave.
Hillsboro, OR 97123
Attn: Kenneth E. Conway
Re: Permit No. ELC2009 -00395
Dear Mr. Conway:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12753 SW 68 Ave.
Project Name: George Fox
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $47.94.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as scope of work changed and permit was not required.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 . 0 www.tigard- or.gov 0 TTY Relay: 503.684.2772
r
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action orRefind form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: I{EC Electric, Inc. DATE: 11/5/09
761 SW Bailey Ave.
Hillsboro, OR 97123 REQUESTED BY: Dianna Howse
Attn: Kenneth E. Conway
TRANSACTION INFORMATION:
Receipt #: 174696 Case #: ELC2009 -00395
Date: 8/4/09 Address /Parcel: 12753 SW 68th Ave.
Pay Method: CreditCard Project Name: George Fox
EXPLANATION: Per applicant's request as scope of work changed and permit was not required.
REFUND INFORMATION:''. . •
•Fee•Description;From. Receipt . • . • Revenue •Account No:.:•'" -: • Refund ` -
Exampl >[BUII D] Permit Fee • • Example: • $ Aiiioiin .'`.
Branch circuits 2200000 -43103 $42.80
12% State Surcharge 1003100 -24001 5.14
TOTAL REFUND: $47.94
APPROVALS:
If under $500 Professional Staff
If under 37,500 Division Manager i! t
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
.. FOR ACCELA SYSTEM ADMINISTRATION.USE:ONLY:
Refund Request Reviewed: Date: i�'' "`_ f By: .. 1 f '
Case Refund Processed: Date:
1: \ Building \ Refunds \RcfundRequesr.doc 04 /13/09
Oct 27 2009 14:48 KECELECTRIC 5036403838 P.1
I.
Community Development
Li n I(! Request for Permit Ac 'on
•
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: KEC Electric, Inc
INVOICE TO: (Business ox Individual)
Mailing Address: 761 SW Bailey Av
City /State /Zip: Hillsboro, Or 97123
Phone. No.: 503- 439 -0904
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (1):
❑ CANCEL PERMIT APPLICATION.
® REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and extlain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel ermit).
Permit #: ELC2009 -00395
Site Address or Parcel #: 12753 SW 68th Ave
Project Name: GFox Restrooms
Subdivision Name: Lot #:
EXPLANATION: the project did not proceede for us, we just replaced a couple
existing fixtures, no permit required.
• i
Signature: _ _ell_ ; — Date: 10/27/09
Kenne . , E Conway
Print Name:
Refund Polity
1. The Director or Building Official may authorize the refund of:
a) any fce which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or caner ed before any review effort has bccn 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 an plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection tequ ts.
2. Refunds will be returned to the original Payer in the same method in which payment was received. I lease allow 1 -2 weeks for processing refunds.
FOR (7FFFCR USE ONLY
Rte to Sys Adrnin: Date B Rte to Bldg Adtnin: Date j/ , i By
Refund Processed: Date �% .•!�. _' B 1 .. 0 Invoice Processed: I a Date By
Permit Canceled: Date ///4 J B ' : ,r' Parcel Tag Added: Date By
Receipt # ,�') Date %` �i;' >' Method (' Amount $
L \Building \ Forms \RegPermicAction.doc Rev 07/26/07
• CITY OF TIGARD RECEIPT
L' . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
/ ',ftlft £-
Receipt Number: 174696 - 08/04/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2009 -00395 Branch Circuits wo /Purchase Service or 2200000 -43103 $53.50
Feeder
ELC2009 -00395 12% State Surcharge - Electrical 1003100 -24001 $6.42
Total: $59.92
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 005439 LSELLERS 08/04/2009 $59.92
Payor: Kenneth E Conway
Total Payments: $59.92
Balance Due: $0.00
Page 1 of 1
r
CITY OF TIGARD RECEIPT
s . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
T1c.AItID
Receipt Number: 175947 - 11/06/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2009 -00395 $ -47.94
Total: $47.94
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 005439 DROWSE 11/06/2009 $ -47.94
Payor: Kenneth E Conway
Total Payments: $ -47.94
Balance Due: $47.94
51- Tidemark
S ystem Administration
Ill " "' I Finance Department Request
Date: //6/0 y
To: 1 Liz Lutz
Angela McCoy
From: Dianna Howse/
Re: Receipt #: / 2 cc 97, 1 y L 9 (..
Please process this request as follows:
Journal Entry (route copy of JE to
Dianna Howse).
Reversal (fees have been reversed on
Revenue Account Report).
` Credit Card Return (fees have been
reversed on Revenue Account Report).
Other /Explanation:
,E, 70E,2"fr- r= 4 --- S .
Thank you! - /
I: \ Building \ Forms \RteSlip•FinanceReq.doc
Page 1 of 1
• CITY OF TIGARD ELECTRICAL PERMIT
• a : , COMMUNITY DEVELOPMENT Permit #: ELC2009 -00395
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 08/04/2009
Parcel: 2S 101 AD02400
Jurisdiction: Tigard
Site address: 12753 SW 68TH AVE
Subdivision: WEST PORTLAND HEIGHTS Lot: 32
Project: George Fox
Project Description: Install (2) branch circuits for restroom remodel.
Owner: FEES
GEORGE FOX UNIVERSITY Quantity Description Date Amount
ATTN: FINANCIAL AFFAIRS, 414 N MERIDIAN
NEWBERG, OR 97132 2 crt Branch Circuits 08/04/2009 $53.50
wo /Purchase Service or
PHONE: Feeder
1 ea 12% State Surcharge - 08/04/2009 $6.42
Electrical
Contractor:
KEC ELELCTRIC INC
1281 NE 25TH AVE # K
HILLSBORO, OR 97124
PHONE: 503 - 439 -0904
FAX: 503- 640 -3838
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp:
Total $59.92
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180
days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
r ��. �� �l �j I - }
Issued By: l I l ' lX ,[ I� 1 Permittee Signature: Q Tipp l� COCA 11Q 11
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale, lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR. ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each Inspection.
_ - nil 29 2009 10:45 KECELECTRIC 5036403838 p.l
*l.- r
Electrical Permit Applicatr _ OF \f E t t,,; (11.1.1(-1. USE (1N1.1•
City of Ti acrd Received
`J g u I 2009 Permit No.: 0 ei
11 Phone: 503.639.4 t 71 Fax: 503 9
.-- Y 13125 SW Rail Blvd., Tigard,OR 9722JL 2 9 Date/3 ! �IC7` /� •c3 is
.58 Plan By: other P ewit
��: PZr�p4.00IQ�
-t.1 c> > 1; t , inspection Line: 503.639.4175 C TY OF �BGAR® Date Ready/By: !mils 6J See Page 2 fee
Internet www_tigard -or v aufled/Mcth Supplemental Information
r� pie
.. ....:,� .. �.._ -__ __:- ::.lv- ._.:.'' __ - ia _ _ -- c!`.!ii:__ _ -:vil -- -- - -
-., .,:,.,. ". _... .._. -: . 4P .::: _.:::: :•. 'Al::...T.:_... _: -•n•r _ ...._ i til i 'A - t =-- _ it ' 2: ,- ,._r"a: - tiE rii ^ mi:..::,_:
......... _.. •�...:, ... -.. 1 .._ - _. -_.. .. �.:i':: - = �l.�i t. ^::cam _....4J - :c .. : ..._�r::.._ UI • -' u �i'•_....._- � ?ili::a..� fii. __.._ !!:,r..... ;....
.. : : ..- ... t�:t-.....__.. -._.: ..,. .;, �;.>~- ...,,,. _li. t >I__- ...t7�. �: •:- �nm ; -: ...? liv:::-.:_ �-. �t ts ir; �_".. LWU , c:'i�z'c -� e;9 ?.i�EicC-::::�?'� ;: ;,-
❑ New construction ®Addition /alteration/replact went Please check a0 Out apply (submit b sets of plane Whams checked below)'
❑ Demolition Other: 0 Service m feeder 400 amps or more ❑ Building ova three stories
i. .._. .
- r .... LUrretl
' i::::::_ :•• ; > ;::= :.::. _. ; s,,,.__.�{�: , r- i .yy" » { t s - - - - exceeds l0,1300 at 150 wltsor oati
, : ,. - -: �.. , GPs
� - ': Sim ; i`- _ c : 7 :•::
Ei= '.= 1�V:.ra:. 2L {.i5
..:, ..i ....___._ H ',ld' ; ;s Vi? iiiEE� =d �2 v.:: ?�? B
® Commercial /industrial leas to ground, m exceeds 14,000 ❑ builds commercial-we agricultural
❑ 1- and 2- family dwelling
❑ Accessory building amps for ail other installations, buildings.
❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or
., ,, . ! 1 ! :fiat G1 I.:.. '>; a ._ derived system.
_... ..• ... .1.:. ,.,........_ ., :::. ::::.:• �, f .L!'°'':.- -......__..:_... ._, ..... .,�. ❑Additioaof new matsaloadof 0"A". ,E ».,1.y
Job no.: 09 -1049 I Job site address: 12753 SW 68 Ave 10011P or more. occupancy.
❑ Six or tare residential units. 0 Recreational vehick parks.
City/State/ZIP: Portland, Or ❑ Health fatalities. CI Supply voltage for more than
0 Baia dous locations. 600 volts nominal.
Suite/bldg./apt. no.: I Project name: George Fox Restroom rmdl O Service or feeder 600 amps or tame.
, .-- ' • fit, ... ., ..
Cross street directions to job site: Dana ptioa 7 ov 1 Fed 1 Total I •
New residential single- or multi- family dwelling unit.
Includes attached garage.
Subdivision: 1 Lot no.: 1,000 sq. R. or less 145.15 4
Tax mapiparcel no.:
Ea. add'i 500 sq. ft or portion 33.40 1
•....
�� : _ ......_.... energy', residential
75.00 2
. ". _ .k; • :w . : : i:.:G .7 ' , - � .t.,� • e' :......... ....._ :vc_'._ , n ., .'.4:;y+ - .._'i��i s = _ _e;.° +�i.5e' � ,.. (with above sq. R )
Limited energy, multi - family
Remodle existing restrooms (2) residential (with above sq. ft) 75.00 2
Services or feeders inatallation and/or relocation
..... _.:• IIX
...:,, .... - : .._. - �: .... .. -- -. _.... -- -- �� °��� __ - - 201 amps
to 400 s
:- .- .: ::+ ' - . - +`i•:•;a ?:> _.. P �P 10615 2
Name: 401 amps to 600 amps 160.60 2
- 601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/ State/ZIP: Temporary services or feeders installs don, alteration, and/or
relocation
Phone: ( ) Fax: ( ) 200 amps or less 66.85 1
Owner installation: This installation is being made on property that 1 own which is not 201 amps to 400 amps 100.30 2
intended for sale, lease, rent, or exchange, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2
Owner signature: Date: Branch circuits new, alteration, or extension, per panel
1,:k
:t
- .,..: 1.
.. _. "....... :- :::- :
::: : -: ::.. . -- I. ":z�;iu ;�E above service or fader fee, 6.65 2
each branch circuit
Business name: B. Fee for branch circuits
Contact name: without service or feeder fee, 1 46.85 46 2
first branch circuit
Address: Each add'I branch circuit 1 6.65 6.65 2
Miscellaneous (service or feeder not included)
City/ State/ZIP: E ach manuf actured or modular
dwelling se rvice tu d /or feeder 90 2
Phone: ( ) Fax; : ( ) Reconnect only 66, 2
E -mail: Pump or irrigation circle 53.40 2
. �:.._.. -'��'�R. " :::�' '.... : ..� - - - outline lighting 53.40 2
._ . ,. .. .. .
_..._....:. _..." r � ? v:�..: ..;:'_;:_.,, .: :::::::._:: ;: °:. _..;�+:. � Sign or g g
Business name: KEC Electric, Inc - Signal circuit(s) or limited -
energy panel, alteration or
Address: 761 SW Bailey Ave extension. Describe: Page 2 2
City/ State/ZIP: Hillsboro, Or 97123 Each additional inspection over allowable in an of the above
Phone: (503) 439 -0904 Fax: (503) 640 -3838 Per inspection 62.50
Investigation per hour (1 hr min) 62.50
CCB Lic.: 99267 Electrical Lic.: 34 -426C Su rv. Lic.: 4489S Industrial plant per hour 73.75
Suprv. Electrician signature, -: -; lte1T+.1E °' !::e.;••i s
Su
p gnature, wired: Subtotal: 53.50
Print name: Kenneth E. Conway 7 Date: 1/29/09 Plan review (25% of permit tee):
State surcharge (12% of permit fee): 6.42
Authorized signature: TOTAL PERMIT FEE: 59.92
Print name: Date; 11115 permit application eap{res if a permit is not obtained within 180
days after it has been accepted as complete.
1.1B„ildi • Number of inspections allowed per permit.
neennitslELC- PernJitApp.doc 05!23;06 440.4615T(11tOS1COM WEB
p rti A`(\
City of Tigard, Oregon ° 13125 SW Hall Blvd. ° Tigard, OR 97223.A* X
,a+s i Jr s 2
kel
l t l ' f t � f \ u l
November 6, 2009
KEC Electric, Inc.
761 SW Bailey Ave.
Hillsboro, OR 97123
Attn: Kenneth E. Conway
Re: Permit No. ELC2009 -00395
Dear Ivlr. Conway:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 12753 SW 68 Ave.
• Project Name: George Fox
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $47.94.
n Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as scope of work changed and permit was not required.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
1: \ Building \ Refunds \ Administration \LtrRefund- CancelPermit.doc 01/16/07
Phone: 503.639.4171 o Fax: 503.684.7297 o www.tigard- or.gov o TTY Relay: 503.684.2772
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Pavable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: KEC Electric, Inc. DATE: 11 /5/09
761 SW Bailey Ave.
Hillsboro, OR 97123 REQUESTED BY: Dianna Howse
Attn: Kenneth E. Conway
TRANSACTION INFORMATION:
Receipt #: 174696 Case #: ELC2009 -00395
Date: 8/4/09 Address /Parcel: 12753 S \X% 68th Ave.
Pav Method: CreditCard Project Name: George Fox
EXPLANATION: Per applicant's request as scope of work changed and permit was not required.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
Branch circuits 2200000 -43103 $42.80
12% State Surcharge 1003100 -24001 5.14
TOTAL REFUND: $47.94
APPROVALS:
If under $500 Professional Staff
If under $7,500 Division Manager 1 I t"
e
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: e.�:`'': "F� B -4
Case Refund Processed: Date: I By: ;
l:ABuilding \Refunds \Rcfunditequest_doc 04 /13/09
Oct 27 2009 14:48 KECELECTRIC 5036403838 p.l
% RECEIVED
7
,{ WWW OCT 2 7 2009
. ' .15 CITY OF TIGARD Community Develo ment
' " ' ' UILDING DIVISION Request for Permit Ac Won
T 11�; } ,�,t L� a
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 n Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: KEC Electric, Inc
INVOICE TO: (Business or individual)
Mailing Address: 761 SW Bailey Av
City /State /Zip: Hillsboro, Or 97123
Phone No.: 503 - 439 -0904
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
❑ CANCEL PERMIT APPLICATION.
® REFUND PERMIT FEES (attach receipt, if available).
(l INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRAC'T'OR FROM PERMIT (do not cancel permit).
Permit #: ELC2009 -00395
Site Address or Parcel #: 12753 SW 68th Ave
Project Name: GFox Restrooms
Subdivision Name: Lot #:
EXPLANATION: the project did not proceede for us, we just replaced a couple
existing fixtures, no permit required.
Signature: �e��. _ , � i Date: 10/27 /09
/Kennet , E Conway
Print Name:
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 whin 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 an plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requ: ts.
2. Refunds will be returned to the original Payer in the same method in which payment was received. lease allow 1 -2 weeks for processing refunds.
Rte to Sys Adrnin: Date B • Rte to Bld: Admin: ( Date j ,, pg B <a:,_� ,.
Refund Processed: Date // B . s �;,„_ - Invoice Processed: ' Date B
Permit Canceled: Date // / - B ' ;A.. Parcel Tag Added: Date By
Receipt # / 9 ? ( Date tV J/ o y Method ( Amount $
I: \Building \ Farms \RegPennirAcrion.doc ev 07/26/07