Permit CITY OF TIGARD SITE WORK PERMIT
1 ; COMMUNITY DEVELOPMENT Permit #: SIT2013 -00010
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 04/23/2013
Parcel: 2S 102AB05000
Jurisdiction: Tigard
Site address: Burnham
Project: Main St. Off - Street Parking Lot Subdivision: KINGSTON Lot: 2
Project Description: Building new parking lot for the City of Tigard
Contractor: D & T EXCAVATION INC Owner: CITY OF TIGARD
PO BOX 3767 13125 SW HALL BLVD
WILSONVILLE, OR 97070 TIGARD, OR 97223
PHONE: 503 - 263 -2607 PHONE:
FAX: 503 - 263 -2648
FEES
Description Date Amount
Specifics: Permit Fee - Site Work 04/23/2013 $926.16
Plan Review 04/22/2013 $602.00
Type of Use: COM 12% State Surcharge - Building 04/23/2013 $111.14
Class of Work: ALT Erosion Control w /Permit - Ping 04/23/2013 $225.00
Info Process /Archiving - Sm $0.50 (up to 04/23/2013 $7.50
Project Valuation: $126,000.00 11x17)
Site Specifics:
Excavation Volume: 300 cu. yd.
Fill Volume: 300 cu. yd.
Impervious Surface: sq. ft.
Engineered Fill: No Soil Report Required: No
Paving: Yes Grading: Yes
Landscaping: Yes Site Prep: Yes
Storn Drains: Yes Retaining Wall: No
Fire Underground: No Accessible Parking: Yes
Fence: No
Total $1,871.80
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 "cation - -r. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules
or ' ect questions to OU b -. :1 or 1.800.332.2344.
I sued By: / Permittee Sure: �II� , , �� �
Call 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
Building Permit Application
Site Work RE EI � FOR OFFICE USE ONLY
UE Received
h nnit Nu. y Va0
CI}� of Tigard
�.
City g Date /By: l
1 = Phone: 503.718.2439 Fax: 503.598.1960 Date /By:
• 13125 SW Hall Blvd., Tigard, OR 97 223 APR 2 013 Plan Review 23 7 Other Permit: V if -006/0
TIGARD Inspection Line: 503.639.4175 CITY OFTIGARD Date Read / 1 r i 4 ® See Page 2 for
Internet: www.tigard- or.gov No ti fied / Method: y �3 �3 Supplemental lnformadon
BUILDING DIV 4146.4. kv .
AND 2- FAMILY D
ew construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
❑ Addition/alterationireplacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY µ ** �.. �4:.. m ■ work indicated on this application.
OF CONSTRUCTION
❑ I- and 2- family dwelling ❑ Commercial /industrial Valuation: $ `Z (yr (X)L3 , —
❑ Accessory building ❑ Multi- family Number of bedrooms:
❑ Master builder titer Number of bathrooms:
JOB SITE INFORMATIONAFD LOCATION Total number of floors:
Job site address: igtArnhwr, 5`., O A�a2.trSS) New dwelling area: square feet
City/State /ZIP: 7; lily- 0 (l 111 Garage /carport area: square feet
Suite/bldg. /apt. no.: NA_ Project name: N e44.1 cf ( i k
- slice+ ,� Covered porch area: square feet
Cross street/directions to job site: P COT .V' Deck area: square feet
SLV M c ■ n c + Other structure area: square feet
x
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: ,-. 4' I Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: pC f O 911 605N90 a ,'0 $7D� Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
lm DESCRIPTION OF WORK work indicated on this application.
Valuation: $
Q'1d .'e e Viet.,. trek (off { C cf
Existing building area: square feet
T; S,.r �
New building area: square feet
PROPERTY OWNER ( TIMI
TENANT Mil Number of stories:
Name: ( t. o f i 5 '., Type of construction:
Address: rk 12 S -- SL., (^x/ .0 tivJ. Occupancy groups:
City/State/ZIP: ; c ec r c i 5 Existing:
Phone: (5D3) 7 1 21- 7_4 L t_ Fax: (S3) ( Z y - cos New:
(& APPLICANT ❑ CONTACT PERSON
Business name: IT �. Xch.- a.. TPAc All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name:
tvr k c). i C..--kil t under ORS 701 and may be required to be licensed in the
Address: 7, C j30 K 31 1. 7 jurisdiction in which work is being performed. If the
applicant is exempt from licensing, the following reasons
City/State /ZIP: (i
I S V ,z v. I It R 4? 0 V apply:
Phone: (S -2 Fax:: ) 2 k - ZC 1 IQ.
E-mail: —
(71-$' o€? di- r)(cc.vc 1111,-, • cL e.•-
CONTRACTOR
Business name: sT C X «vim h TIN-.- t KC.
Address: � 0 , u x y? ('—)
Structural plan review fee (or deposit):
City/State /ZIP: (N 1 I Sv n u. t I( 0 12 co 0 7 C 7
Phone: (9 1 c 1 - 2 6 U Fax: ( j ) '2 ( FLS plan review fee (if applicable):
Total fees due upon application:
CCB lic.: (S c Q 51\`0,
Amount received:
Authorized signature: This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: a QS /104,4_ Date: C V/ 7 /43 * Fee methodology set by Tri-County Building Industry
Service Board.
I: \Building\Permits \SIT- PermitApp.doc 10/01/09 440- 4613T(I 1 /02 /COM /WEB) (ep]-- 0-2)
City of Tigard: Site Work Permit Checklist
Page 2 - Supplemental Information
Commercial, Multi - Family and One- and Two-Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads), or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way, or wetland, the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below, unless otherwise noted.
Excavation Volume: `3 vU c i cu. yds.
Grading Volume:
(Soils report required for >5,000 cu. yds.) app C cu. yds.
Fill Volume:
(Fill exceeding 12" in depth shall be compacted to
90% of maximum density) 10 p c. cu. yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
❑ Concrete
PO UO KA ❑ Other:
*Total new impervious area including all buildings,
sidewalks, and r avin . : s • . ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See "Site Work Permit Application - Plan Submittal Requirements" attached.
The following must accompany this application:
❑ Site Plan with Vicinity Map showing ADA ❑ *Parking (including ADA) and Lighting
compliance Plan
❑ Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details ❑ Soils Report (if required)
❑ Retaining Structures ❑ Fire Line
*Does not apply to One- and Two - family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL # of Plans L Valuation: ,,,,,rmit Fee:
(New, Additions or Required at $.00 to $500.00 $51.09 n inin,u,» pcnnit fee
Alterations) Submittal $500.01 to $2,000.00 S51.09 for the first $500.00 and
$2.69 for each additional $100 or fraction
Commercial 3 thereof, to and including $2,000.00.
$2,000.01 to $25,000.00 $91.44 for the first $2,000.00 and
Multi - Family R - Occupancy 3 $10.76 for each additional $1,000 or
fraction thereof, to and including
$25,000.00.
One- & Two - Family Dwelling 2 $25,000.01 to $50,000.00 $338.92 for the first $25,000.00 and
$8.06 for each additional $1,000.00 or
fraction thereof, to and including
$50,000.00.
$50,001.00 to $100,000.00 $540.42 for the first $50,000.00 and
$5.38 for each additional $1,000.00 or
fraction thereof, to and including
$100,000.00.
S100,000.01 and over $809.42 for the first $100,000.00 and
$4.49 for each additional $1,000.00 or
fraction thereof.
I:\Building\Permits \SIT - PennitApp.doc 05/25/2012 2
Building Division
Development Code Provision Review
T I G A R D Commercial Projects with Approved Land Use
Building Permit No.: (I .9.0t — QUD /O
Land Use Casefile No.: J F}(Z -'9,D 1 0l —DOO (D / -0 s
Routed Plans:
Submittal Date: 4/4 / 3
Submittal Date:
Submittal Date:
To the Applicant:
Each review type must be approved. If the plan is not approved, please revise and resubmit three (3) copies
to the Building Division. Only checked (✓) items are approved. Items not approved and those listed in the
notes must be revised prior to re- submittal. For questions please contact the appropriate staff person(s) listed
above each section.
STAFF: please only mark those items on the left side that are approved.
w
Planning Review (contact e- - "IJ C lei at 503 - 718 - 24 or c e of / G @tigard - or.gov)
Land Use Approval
pi Building Plans Match Approved Plan: Yes ❑ No ❑
ca Maximum Building Height IV /f1
IX Conditions Met
L l' Street Trees
CZ Protected Trees
Notes: Coe,el;4;4A. - (1a( Sigk Di "tee ell t4,J 4" be. el%
Ov: &A 1 1 Spe c--& Oi .
Original Plan: Approved , Not Approved ❑ Date: 4 - - 1 3
Revision 1: Approved ❑ Not Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
(Review Continues on Page 2)
Page 1 of 2
Engineering Review (contact Mike White at 503 -718 -2464 or MikeW @tigard- or.gov)
❑ Actual Slope:
❑ PFI Permit #
❑ Conditions Met
Notes:
Original Plan: Approved ❑ Not Approved ❑ Date:
Revision 1: Approved ❑ Not .Approved ❑ Date:
Revision 2: Approved ❑ Not Approved ❑ Date:
•
Permit Coordinator Review (contact Albert Shields at 503 - 718 -2426 or albert @ tigard- or.gov)
❑ Planning Okay to Issue Permit ❑ Arborist Okay to Issue Permit
❑ Engineering Okay to Issue Permit
Notes:
Original Plan: Date Sent to Applicant:
Revision 1: Date Sent to Applicant
Revision 2: Date Sent to Applicant
Okay to Issue Permit: Yes ❑ No ❑
Date Routed to Building:
Page 2 of 2
74 i.
DTI GARDe
City of Tigard
June 5, 2013
City of Tigard
Attn: Kim McMillen
13125 SW Hall Blvd.
Tigard, OR 97223
Re: Permit No. SIT2013 -00010
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 2S102AB0500/2S102AB05100
Project Name: City of Tigard - Off Street Parking
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $332.29.
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): Per building official's request as the project valuation was reduced from
$126,000 to $78,952.64 resulting in the reduction of permit fees. Refund balance due to
payor.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/ c .. .0' 4 11 , ....,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
City of Tigard
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 Request for 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: City of Tigard DATE: 5/16/2013
Attn: Kim McMillen
13125 SW Hall Blvd. REQUESTED BY: Dianna Howse
Tigard, OR 97223
TRANSACTION INFORMATION:
Receipt #: 191077 Case #: SIT2013 -00010
Date: 4/23/2013 Address/ Parcel: 2S102AB0500/2S102AB05100
Pay Method: CreditCard Project Name: City of Tigard - Off Street
Parking
EXPLANATION: Per building official's request as project valuation was reduced from $126,000 to
$78,952.64 causing a reduction in permit fees. Refund balance due to payor.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Site Work Permit Fee 230 - 0000 -43104 $229.72
12% State Surcharge 100- 0000 -24001 27.57
Erosion Control 100 - 0000 -43130 75.00
TOTAL REFUND: $332.29
APPROVALS: SIGNATURES/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 ON
Case Refund Processed: � Date: I /.s //3 I By: _ 47' t y
I: \ Building \Refunds \RefundRequest.doc x 09/01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
c
III a a Request Permit Action
-r I G A It 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 NrCity Staff
(check one)
/ R "X6er 19 1061
REFUND OR Name: t , ,,, 0 3 a � 3 ?L.s,J R¢ v-T L
INVOICE TO: (Business or Individual) S p 1 . 3 j
7 3 a q1 3 1)4 n !-ris: ecHeAz6iE
_j /Skrlo ailing Address: \ FAcr M1077
/°C4-A/ /L�?// ' . 4 T Elc crViy /n/C d 6 4 os^rF L Ai 6 —
City/State /Zip: /o d 4 oX 37(07 , P1 /L, Sosvvi [.cam / p 9 '7o 7o
P672 "ff i G(7)' OF 776-1} /c //`9 /&fe .yi cL EJ
rf- C .. / 3 / Sec) ,4A1 - 14_ c_,r/ 7 f -2z) e, 97 .2.23 011ee-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
El CANCEL /VOID PERMIT APPLICATION.
2r 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 #: rjST ae'I 3 - 00010
Site Address or Parcel #: Rvi2n1 I-IA ,3_c / C7 Z ,4 0 50 06
Project Name: /%Ip riU 57 !,1F s T72.6e - T r
Subdivision Name: Lot #:
EXPLANATION: Uyc.Rsmr&D VA 1-..n o-A- g i btAct O FRc •1 aa6,000 A
a ; ' 5 , c 1.N. e . P1 cNTRA Crv,c — ;' &/ilrr 4 SN2c _ . ' a6
P AA-D EL( Carr' -r^^ /4.I1 a-,1w P- cAA.D)
Signature: 1 Date: C 7 - 1 3
Print Name: //4R }L /&N 'b GM h. ` fin/
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 B - Rte to Bid: Admin: Date 6�/1AIM B is
Refund Processed: Date • At Gill B t 2 Invoice Processed: Date B
Permit Canceled: Date /l/ 4 By 11 7" Parcel Tag Added: Date By
Receipt # Date Method Amount $
1:\ Building \ Forms \RegPemvtAction.doc Rev 05/25/2012
Note: Storm Drainage Improvements are Public
Main St Off -St Parking Lot Improvements
Submitted Project Cost $ 126,492.00
Items not to be included in Project Valuation
Description Quantity Unit Unit Price Total
Mobilization 1 LS 8045.77 $ 8,045.77
Traffic Control 10 HR 42 $ 420.00
Burnham Sidewalk in RW 450 SF 5.83 $ 2,623.50
Commercial Driveway approach 1 LS 3230.89 $ 3,230.89
Connect SD Pipe to Extg. - Public 1 EA 498.77 $ 498.77
10" SD Sewer Pipe 180 LF 34.16 $ 6,148.80
6" SD Sewer Pipe 4 LF 70.98 $ 283.92
Poured in Place Area Drain 1 EA 1500 $ 1,500.00
Area Drain Type II 2 EA 1392.53 $ 2,785.06
Cleanout 2 EA 730.48 $ 1,460.96
WO Stormfilter CB 1 EA 7121.92 $ 7,121.92
Landscape & Irrigation 1 LS 13269.77 $ 13,269.77
City Project Sign 1 EA 150 $ 150.00
Project Costs (to be subtracted) I $ 47,539.36 I
(Estimated Project Valuation for Bldg. Permit $ 78,952.64 I
CITY OF TIGARD FEE AND PAYMENT HISTORY
-v
i • . 13125 SW Hall Blvd., Tigard OR 9722
503.639.4171
T IGARD
SIT2013 -00010 - Burnham, TIGARD, OR
, I
Revenue ! � ' ° V Payment
Fee Description Account Number Fee Amount (1Z! Invoiced /2„/2„e" L Paid Date Paid Method Receipt # Due
Permit Fee - Site Work ••7 -f 4 230- 0000 -43104 $926.16 6?c , VV$926.16 .2 Z.2,2. $926.16 4/23/13 Credit Card 191077 $0.00
Plan Review TO Aq2. 230- 0000 -43106 $602.00 , /97, 3/ $602.00 4/22/13 Credit Card 191069 $0.00
12% State Surcharge - Building rd k /#7 100 - 0000 -24001 $111.14 P,7 S7 $111.14 29. 57 $111 14 4/23/13 Credit Card 191077 $0.00
Erosion Control w /Permit - Ping TD j 100 - 0000 -43130 $225.00 /5-0.00 $225.00 '75 of $225.00 4/23/13 Credit Card 191077 $0.00
Info Process /Archiving - Sm $0.50 (up to 230 - 0000 -43135 $7.50 7. 50 $7.50 —El-- $7.50 4/23/13 Credit Card 191077 $0.00
11x17)
Totals for Fees $1,871.80 $1,871.80 $1,871.80 $0.00
Receipt # Payment Method Check # Payor: Receipt Date Receipt Amount
191069 Credit Card Derek Osterholme D 04/22/2013 $602 00
& T Excavation
191077 Credit Card Kim McMillen - City of 04/23/2013 $1,269.80
Tigard
Total Payments: $1,871.80
Balance Due: $0.00
rider/ /LE//E&J /1- E,C-u ..I/ .. -g `f `f 1 . 3
V
� 5
- 'tGARD�
City of Tigard
June 5, 2013
D & T Excavation
Attn: Derek Osterholme
PO Box 3767
Wilsonville, OR 97070
Re: Permit No. SIT2013 -00010
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 2S102AB0500/2S102AB05100
Project Name: City of Tigard - Off Street Parking
Job No.: N/A
Refund Method: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $149.31.
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): Per building official's request as the project valuation was reduced from
$126,000 to $78,952.64 resulting in the reduction of permit fees. Refund balance due to
payor.
If you have any questions please contact me at 503.718.2430.
Sincerely
4 ' "11."
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard or.gov
Er , City of Tigard
TIGARD Accela Refund Request
co
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request forPermit 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: D & T Excavation DATE: 5/16/2013
Attn: Derek Osterholme
PO Box 3767 REQUESTED BY: Dianna Howse
Wilsonville, OR 97070
TRANSACTION INFORMATION:
Receipt #: 191069 Case #: SIT2013 -00010
Date: 4/22/2013 Address /Parcel: 2S102AB0500/2S102AB05100
Pay Method: CreditCard Project Name: City of Tigard - Off Street
Parking
EXPLANATION: Per building official's request as project valuation was reduced from $126,000 to
$78,952.64 causing a reduction in permit fees. Refund balance due to payor.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 $ Amount
Plan Review 230- 0000 -43106 $149.31
TOTAL REFUND: $149.31
APPROVALS: SIGNAT • S D • TE:
w
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 AD INISTRATION USE ONLY
‘7_5 ,C3
Case Refund Processed: I Date: I � I By: I -
I• \Building\ Refunds \RefundReguest.doc x 09 /01/2010