Permit ! Community Development vp ! D
TIGARD Request for Permit Action -/3
T O: 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)
Mailing Address:
City /State /Zip:
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 #: SWR2013 -00098
Site Address or Parcel #: 11475 SW Pacific Hwy
Project Name: Gatos s Pub & Eatery
Subdivision Name: Lot #:
EXPLANATION: Created in error. Some confusion with customer's order
- PLMAD /3 —00/3/
Signature: AA4Ajitti C Date: 4/24/13
Shirley Treat
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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 apphcauon is canceled before any plan review effort has been expended
e) not more than 80% of the building permit fee for issued permits pnor to any Inspection requests
2 Refunds will be returned to the ongmal 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 By Rte to Bid! Admin: Date B /av�
Refund Processed: Date V/ /#9 B � Invoice Processed: Date By
Permit Canceled • Date f B /�;, • .rce Ta: Added: Date B
Receipt # Date Metho. Amount $
1. \Building \ Forms \RegPemntAcuon doe Rev 07/26/07
A ccumulative S ewer Tall
I III C Tenant Name: Gator's Pub & I : SV \'R # 2013 -00098
Site Address: 11475 SW Pacific I Iwv, "1'igaid, OR 97223 V 0 I PLM # 2013 -00131
1
1(, n K D Parcel #: 1 S 136AD04301
(Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total values
Bapuscry /Font 4 0 0 0 0 0
Bath: - "l'ub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash: - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher: - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Dunking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink: - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 1 5 1 5
- 4 inch 6 0 0 0 0 0
- Car Wash 6 0 0 0 0 0
Garbage Disposal.
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 111 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink
- Lay/Bar - Non -Food Related 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Com /Sere /Util - Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 1 5 1 5
Current Fixture Value 5 divided by 16 = 0 313 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous EDU
Change 5 divided by 16 = 0.313 over (under) S 1,446 15
Enter EDU Change Here 0 310
Notes:
Authorized Name /Signature: Shirley "Treat Date: 04/24/2013
Building Division
ote: The property owner shall retain the ORIGINAL sewer tally record. I f credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
1•\ Building \ Sewer Tally AScwerl'allyShect -4665 xis 07/01/12