Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 .i ill
■ Request for Permit Action c/24/45 bi.
, It,A RI) 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.gov
TO: 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 14 City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
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 #: § j L C.I —66 l 1
Site Address or Parcel#: 91�j() o 1. 4 i NC 5T !J kiTh•
Project Name: 1 V i \J\//'r
Subdivision Name: p Lot#:
\XPLANATION: ADD:A L'�-fl o ej�-t 1 Trc b b y Pt QL' 4 i-re e- .
x.(21-t '&u( H i Tf/) 15sa1--b T ( ,> A I eTat frr 1-41 —1Thf4TE .
' ee__- . ' -w,02-9,0 I s—OC O 4-.
Signature: - Date: 2//q), -----
Print Name: —�c.igh/ £ 41:),09-(14.e,,14N1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to S s.Amin: Date J/i7��Q Route to Records: Date,3®i E:m
Refund Processed: Date ` ' B /ij Invoice Processed: Date By
Permit Canceled: Date 3 2(0 /c. By ...._.. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09 314...
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Tenant Name: Ivivva ***VOIDI Ac?D ulative Sewer Tally
*** WR ]4-00115
Site Address: 9650 SW Washington Square Rd PI,M# 2014-00354
Parcel#: 1S1260000300
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
value count capped#s value cnmr .aided# added value total#s total values
Baptistry/Font 4 0 0 0 0 0
Bath: -Tub/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 I 0 0 0 0 0
Dishwasher: -Commercial 4 0 0 0 0 0
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash I 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 1 2 1 2
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/41 IP) 16 0 0 0 0 0
-Commercial(to 5 I IP) 32 0 II 0 0 0
-Industrial(over 5 1 II') 42 0 11 0 0 0
Ice Machine/Refrigerator Drain I 0 0 0 0 0
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
Rec.Vehicle Dump station 16 0 II 0 0 0
Shower: -Gang(per head) 1 0 11 0 0 0
-Stall 2 11 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 U l 2 1 2
-Bradley 5 U 0 0 0 0
-Com/Scrv/Util-Food Related 1 U U 0 0 0
Swimming Pool Filter I U 0 0 0 11
Washer-Clothes 6 0 U 0 0 0
Water Extractor 6 0 0 0 0 U
Water Closet-Toilet 6 0 U 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 4 2 4
Current Fixture Value 4 divided by 16= 0.250 Current EDU 1 EDU= $4,900.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 4 divided by 16= 0.250 over (under) $ 1,225.00
Enter EDU Change Here 0.250
Notes:
Authorized Name/Signature: Debbie Adamski Date: 12/3/2014
Building Division
ote: The property owner shall retain the ORIGINAL.sewer tally record. If credits exist,this document will serve as a voucher which must be
ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
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1:\Building\Sewer Tally\Sewer fallyShect_4910._070114.xlsx