Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 D
I ■ r Request Permit Action
i i,;,,li l, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • ww o
I th 1.-'
TO: CITY OF TIGARD J UN I
Building Division Services Supervisor C,� 2 4?014
13125 SW Hall Blvd.,Tigard,OR 97223 1'r,-,
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-o1 LDING�'WIRD
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FROM: ❑ Owner M Applicant ❑ Contractor E] City Staff 41
(check one)
REFUND OR Name: Paula Barsotti
i
INVOICE TO: (Business or Individual)
Mailing Address: 9865 SW Inez st.
City/State/Zip: T and Or. 97224 �iim.
ft.Tigard
Phone No.: 503-620-1669
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): 1
Z CANCEL/VOID PERMIT APPLICATION.
® 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 #: ,a,2,..,4? , 196078 ea4 .„„t c LN13o\`'t - 00\6(5
Site Address or Parcel#: 9865 SW Inez A--
Project Name:
Subdivision Name: Lot #:
EXPLANATION: Not intending to use.
Signature: Pa42 $QJIA Date: fier-7-07,05-6
Paula Barsotti 7,2.SO — SP. c0 = /Y, SO
Refund Policy e , 70 ' r cl , . /. 7
1. The Director or Building Official may authorize the refund of: ,...------
a) any fee which was erroneously paid or collected. op 96 A , /
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S•s Admin: Date aPI'M,-E Rte to Bid!Admin: Date ®�' B LIj
Refund Processed: Date Cy11MII2K.NII Invoice Processed: Date B
Permit Canceled: Date / Ay By,I • Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\ReqPermitAction.doc Rev 05/25/2012
.
I' q
T I GARD
City of Tigard
July 31, 2014
Paula Barsotti
9865 SW Inez St.
Tigard, OR 97224
Re: Permit No. PLM2014-00160
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9865 SW Inez
Project Name: Barsotti
Job No.: N/A
Refund Method: ® Check#214484 in the amount of$64.96.
❑ Credit card "return" receipt in the amount of$ .
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 applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
L
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
ErCity 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 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: Paula Barsotti DATE: 7/24/2014
9865 SW Inez St.
Tigard, OR 97224 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 196078 Case#: PLM201-E-00160
Date: 5/15/2014 Address/Parcel: 9865 SW Inez
Pay Method: CreditCard Project Name: Barsotti
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit 230-0000-43101 $38.00
12°%o State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff �/ L. 7/2 y'�/�
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 ONLY
Case Refund Processed: Date: 7/3//y By �
I:\Building\Refunds\RefundRequestdoc x 09/01/2010
CITY OF TIGARD PLUMBING PERMIT
•
■ ' COMMUNITY DEVELOPMENT Permit#: PLM2014-00160
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 05/15/2014
T f C;A f�>? 9 Parcel: 25111 BA02105
Jurisdiction: Tigard
Site address: 9865 SW INEZ ST
Project: Barsotti Subdivision: INGEBRAND HEIGHTS Lot: 12
Project Description: An(1)hose bib.
Contractor: OWNER Owner: BARSOTTI, STEPHEN A AND PAULA
BARSOTTI, STEPHEN A AND PAULA 9865 SW INEZ ST
9865 SW INEZ ST TIGARD, OR 97224
TIGARD, OR 97224
PHONE: 503-620-1669
HONE: 503-620-1669
FAX:
FEES
Quantity Description Date Amount
1 ea Hose Bib 05/15/2014 $25.02
Specifics: 1 12%State Surcharge- 05/15/2014 $8.70
Plumbing
Type of Use: SF 47 ea Minimum Fee Adjustment- 05/15/2014 $47.48
Plumbing
Class of Work: OTR
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800,3322344.
Issued By: Permittee Signature: `' C
I11. �`rr//�
I. . .��
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.
Plumbine Permit ApplicationRECEIVEI)
Building Fixtures �+ FOR OFFICE USE ONLI
City of Tigard MAY 15 2014 Ry Permit No. ,^
III
•t 13125 SW Hall Blvd.,Tigard,OR 97223 DateBy: lS�� �Ia�IJ/y�Q/(p jJ
: Phone: 503.718.2439 Fax: 503.59 Plan Review Other Permit No
DaDate/By:8.
T I G A R D Inspection Line: 503.639.4175 Date Ready/By: luris ® See Page 2 for
Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: 17 Supplemental Information
TYPE OF WORK FEE* SCHEDULE
❑New construction ❑Demolition For special information use checklist
Description I Qty. I Ea. I Total
®Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
1:1 1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
❑Accessory building SFR(3)bath 500.32
g ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ®Other: t_. AJA CQ,,,,,e _ Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION [ _ Site utilities:
Job site address: CI C Ski.) • T�Z Catch basin or area drain 18.76
City/State/ZIP: J ct 7 a Drywell,leach line,or trench drain 18.76
.,.C t , Of- `7 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: ;0 0 -r-` Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
(3l....8 d r a' S`4-e- '�- Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
(2 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: �o,,� Fixture/sewer cap 25.02
r'�'" _ ?" ��r° � ∎ Floor drain/floor sink/hub 25.02
Address: Cf S St - Garbage disposal 25.02
City/State/ZIP:C( n(- C(7 2,,-L4 Hose bib i 25.02
Phone:( .)'Tj) I LG ci Fax:( ) Ice maker 12.51
❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name: Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotal
Phone:( ) Fax:( )
Minimum permit fee: $72.50 7a 5 a
CCB Lic.: Plumbing Lic.no.: Plan review (25%of permit fee)
State surcharge(12%ofpermit fee) cp, 7O
Authorized signature: P,,,A, TOTAL PERMIT FEE r tfL/,a240
^� � 5 I This permit application expires if a permit is not obtained within 180 days
Print name: A ‘� 3ol m Date: l•�o IY after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02JCOM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee:
Footing drain-In 100' 50.03 0 to 2,000 $121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
3,601 to 7,200 $233.20
Sewer- 1st 100' 62.54 7,201 and greater $327.54
Sewer-each additional 100' 37.52
Water Service-1st 100' 62.54 Medical Gas Systems:
Water Service-each additional 100' 37.52 Valuation: Permit Fee:
Storm&Rain Drain-1st 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50
Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other ec
Ins tions or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
Inspections and including$10,000.00.
Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimum charge-1/2 hour) and including$25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and including$50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional$100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
Baptistry/Font ❑ Any new commercial building with water service 2"and
greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
3" Isometric or Riser Diagram
4" ❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage -Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall
Sink: -Lav/Bar non-food related
-Bradley
-Com/Serv/tltil food related
-Service *Note: lithe fixture work under this permit results in an
Swimming Pool Filer increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
WaterCloset-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
1:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2