Permit Eril. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I C
Request for Permit Action (Vse ,y
T I G A R n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-of.gox
T O: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Er City Staff
Check(✓)on,
REFUND OR Name:
INVOICE TO: (Business or Individual) ��}LD 0 4l Ek ff- 6144 e,,.:4Jrr2u e_Do,)
Mailing Address: P.O�oyc 3o(Dq 9-.
City/State/Zip: L A 04, 7 9-5 4
Phone No.: 5o - 9 2.- c2.4-)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: POI v20 1 `i-00 3'-(_
vtd
Site Address or Parcel#: IOO S O a- A V�
Project Name: p 11 0 -0 0
Subdivision Name: Lot#:
EXPLANATION: rJo-r ,,J CA, 2D S �.2�S �cTto
C(Ty E7e4ferg-- g-e -u.^.l1 . /OD °76 —
Signature: Date: /d/is//T
Print Name: F}b4/ 1' l
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
I O R OFFICE USE ONLY
Route to S s Admin: Date/O Ag♦me'.,ram Route to Records: Date LM B ;—;511
Refund Processed: Date ArTjAM :rrlira' Invoice Processed: Date B
Permit Canceled: Date /0/26//y By ,'%�' Parcel Tag Added: Date By
1:\Building\Forme\RegPermitAction_09-314. oc
y CITY OF TIGARD PLUMBING PERMIT
111 a COMMUNITY DEVELOPMENT Permit#: PLM2014-00342
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/14/2014
Parcel: 1 S136BB00301
Jurisdiction: WASCO
Site address: 10050 SW 82ND AVE
Project: Johnson Subdivision: METZGER ACRE TRACTS Lot: 3
Project Description: Repair/replace approximately 30'of sanitary sewer line.
Contractor: SIERRA CONSTRUCTION&EXCAVATION LLC Owner: JOHNSON,TIMOTHY
PO BOX 30642 CENSONI-JOHNSON, SARAH-BETH
PORTLAND,OR 97294 10050 SW 82ND AVE
TIGARD,OR 97223
PHONE: 503-492-9242 PHONE:
FAX: 503-252-9808
FEES
Quantity Description Date Amount
30 If Sewer Service 10/14/2014 $62.54
Specifics: 1 12%State Surcharge- 10/14/2014 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment- 10/14/2014 $9.96
Class of Work: ALT
Plumbing
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. • the rules
or direct•. : a UNC by calling 503.232.1987 or 1.800.332.2344. `
Issu= By: 'ii`L Permittee Signature: 4111111filw
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. I
Approved plans are required on the job site at the time of each inspection.
Plumbing Permit Application
Building Fixtures FOR OFFICE USE ONI.I
RECEflIED Rece 1/ !
City of Tigard DateBy:ived �� ��/ // �y% Permit No.: �/ -do 3 /"..7___
NI w 13125 SW Hall Blvd.,Tigard,OR 9743-r 1 4 L V, , Plan Review
■ Phone: 503.718.2439 Fax: 503.59 . Date/By: Other Permit No
1 G A R U Inspection Line: 503.639.4175 MARL) Ready/By: lulls lid See Page 2 for
Internet: www.tigard-or.gov CITY OF Ir11K711L) Notified/Method: Supplemental Information
TYPE OF R ILITINV f 1 ►r FEE* SCHEDULE
❑Ne construction 0 Demolition For special information use checklist.
Description I Qty. 1 Ea, I Total
dition/alteration/replacement Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
1-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78
SFR(3)bath 500.32
❑Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Catch basin or area drain 18.76
Job site address: 10050 �(� Iva P1l/=E Drywell,leach line,or trench drain 18.76
City/State/ZIP:
� Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: ---� O 1f jj j0>.. Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:3:91) Page 2 67..Y'#
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
ll Clothes washer 25.02
l ,v �t`Pik t R Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
PROPERTY OWNER I ❑ TENANT Expansion tank 12.51
Name: Fixture/sewer cap 25.02
N Sp ( �M 4'�� Floor drain/floor sink/hub 25.02
Address: y- ifiC.{c: Garbage disposal 25.02
City/State/ZIP: Hose bib 25.02
Phone:( ) 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
Water closet 25.02
CONTRACTOR
Water heater 37.52
Business name: 5�� ogy„-r(.tglk/ Water P�tP in g/D WV 56.29
Address: A - 4j,,py� 3c-.26,11g Other: 25.02
City/State/ZIP: p--1-to tc)¢, (R.-pct"1 Subtotal
Phone: )1/9:9_ V.L() Fax:693)cg5a 9g0 Minimum permit fee: $72.50 7a.S0
CCB Lic.: /9g71fg3 de Plum _Lic.no.:Q�8&� Plan review (25%of permit fee)
`� f State surcharge(12%of permit fee) 5.-)0
Authorized signature: .e/...��:GlJ �� p fir/�,//g - TOTAL PERMIT FEE '(.?b
Print name: Date: This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
^ *Fee methodology set by Tri-County Building Industry Service Board.
te
P ¢° Lic. 1 3g
I:\Building\Pennits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/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-l"100' 50.0; 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 Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
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) t`-r and inektding$2511.004();; ;
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 Stall 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 that meet the qualifications above.
Garbage -Domestic non-food
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: -LavBar non-food related
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter 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 P
WaterCloset-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2
• . V
T'GARD
City of Tigard
October 30, 2014
Sierra Construction& Excavation
Attn: Ubaldo Sierra
PO Box 30642
Portland, OR 97294
Re: Permit No. PLM2014-00342
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10050 SW 82nd Ave.,Washington County
Project Name: Johnson
Job No.: N/A
Refund Method: ® Check#215432 in the amount of$81.20.
❑ Credit card"return" receipt in the amount of$
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): Permit created and issued in error for Washington County jurisdiction.
Refund 100% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
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
IN a
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 PermitAction 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: Sierra Construction & Excavation DATE: 10/23/2014
Attn: Ubaldo Sierra
PO Box 30642 REQUESTED BY: Dianna Howse
Portland, OR 97294 DA
TRANSACTION INFORMATION:
Receipt#: 197999 Case#: PLM2014-00342
Date: 10/14/2014 Address/Parcel: 10050 SW 82nd Ave.,WASCO
Pay Method: CreditCard Project Name: Johnson
EXPLANATION: Created and issued permit in error for Washington County jurisdiction. Refund 100%
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 $72.50
12%State Surcharge 100-0000-24001 8.70
TOTAL REFUND: $81.20
APPROVALS: SIGNA _ ? S 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 ONLY
Case Refund Processed: Date: /e/7,/y By: /
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
10/16/2014 10:40 5036849015 WESTERN PLUMBING INC PAGE 01/02
RECEIVE,
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
li i i • Request Permit Action ocr 16 2014
T G V I, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • . RU
1 ul VISION
TO: CITY OF TIGARD VOID
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 y ,t/ti
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov 7/5/3.0// ,t1V
FROM: ® Owner ❑ Applicant El Contractor II] City Staff
(r.hcrl;one)
REFUND OR Nanic: Western Plumbing, Inc.
INVOICE TO: (13t'stne s of Indcidual)
Mailing Address: 9460 SW Tigard Street,Suite 101
City/State/Zip: Tigard,OR 97223
Phone No.: 503-639-5296
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL/VOID PERMIT A1'PL ICATI()N.
® 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 #: PLM2014-00332
Site Address or Parcel#: 10830 SW Walnut Street
Project Name: Edwards Residence
Subdivision Name: Lot#:
EXPLANATION: Customer has decided to use another company.
Signature: „ ' 1,1 M . ` y _ Date: 10-16-14
Daz�:I�nsen /2 u4✓4 /?-e729,,N/
Print Name: 7.2•So — .57:4ti ro = /Y• So
Jtcfund Policy
1. 1'ht Crmtmumry Development Director or Building Official may authorize the refund of: /i/��� �� a �
a) any fee which wag trmncously paid or collected. . (O
h) not more than t1(r i,of the land use application let when an application a withdrawn or canceled before any review effort has been expanded.
e) not more than t10^v of the land use application fee for issued permit..
d) not more than 110"'a of the building plan review fee when an application is canceled bcf ne any plan renew effort has been expended.
e) not more than 80"a of the building permit lee for issued permits prior to any inspection my-mete.
2. All refunds will be returned to the orgpnal payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Rre to SI-s.Amin: Date i Ei- Rte to Bldg adtnin: , , ITM By Aiii
Refund Processed: Date 0 ,, i emi Invoice Processed: Date By
Permit Canceled: opt � Date
Receipt# Date Method Amount$
I:\Building\Terms\ReVernutActien_04 2614.doe
II n
TIGARD
City of Tigard
October 30, 2014
Western Plumbing
Attn: Dana Jensen
9460 SW Tigard St., Ste 101
Tigard, OR 97223
Re: Permit No. PLM2014-00332
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10830 SW Walnut St
Project Name: Edwards
Job No.: N/A
Refund Method: ® Check#215449 in the amount of$64.96.
n Credit card "return" receipt in the amount of$
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 customer cancelled job. Refund 80% of
plumbing permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
L/r) -70 e——
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
s . 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: Western Plumbing Inc DATE: 10/23/2014
Attn: Dana Jensen
9460 SW Tigard St, Ste 101 REQUESTED BY: Dianna Howse
Tigard, OR 97223
TRANSACTION INFORMATION:
Receipt#: 197879 Case #: PLM2014-00332
Date: 10/06/2014 Address/Parcel: 10830 SW Walnut St
Pay Method: CreditCard Project Name: Edwards
EXPLANATION: Customer cancelled job. 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 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
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 ONL
Case Refund Processed: Date: _ /ty/ery By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010