Permit Mar. 3. 2015 11 : 23AM No. 0798 P. 2
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IN City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENRECEIVEP
1, Re uest for Permit Action •
q 2015
I ,, ,, ;, I , 13125 SW Hall Blvd. •Tigard, •Oregon 97223 • 503718-2439 •www.tigar or.go
WV OF I'IGAkD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Pax; 503-598-1960 TigardBui ldingPertnits @tigard-or.gov .
FROM: 0 Owner 'Applicant Contractor ❑ City St l
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REFUND OR Name:
INVOICE TO: (811311148 or individual) S(4 J S-e C_ .4 Al SO L147704,1-
Mailing Address: 3s-IC) A)f i- . ROA}-b
City/State/Zip: /1/14 L wAc, f e ale A) 1 ?2(A
Phone No.: SU 3 ac) IQ-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
►Jil CANCEL/VOID PERMIT APPLICATION.
1 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
• INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: 1~LRaClIc OOO
Site Address or Parcel#: '7 55 5 ) 5kik) DA-R.i M(1U/VI 0-T147-
Project Name: CUSr CO Q I I t a
Subdivision Name: PALS' L /kG fit S Lot#: ...)
EXPLANATION: ,S-F A.Iv L -y CA 4011.4-T 67GUJ-CCU. 'CO 13 --
Signature: (C f _ Date: 3-,
.. . Print Name:. .. .S C/- 1lAiGG �-
-- - -. .. .
,fund Policy
1. The city's Community Dcvclopmtn t 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 fcc 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. 7.0° - 6o . P, ' /s'Uzi
9.cry - ' .20 - —
FOR OFFICE USE ONLY
Route to S s Admin: Date_ imm i Route to Records: Date AMM i%falig
Refund Processed: Date yam® B. •7r Invoice Processed: Date B
Permit Canceled: Date y/ Is B C'• Parcel TIT Added' Date By
l:\Building\Forms\RegPennitAction` 23 4.doc
■
1111 ii
TIGARD
City of Tigard
April 2, 2015
Stanley Security
Attn: Steven Snyder
3810 SE Naef Rd
Milwaukie, OR 97267
Re: Permit No. ELR2015-00046
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7850 SW Dartmouth St
Project Name: Costco #0111
Job No.:
Refund Method: ® Check#216965 in the amount of$67.20.
❑ Credit card "return" receipt in the amount of$ .
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): 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,
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
31,,, 2 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 fir 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: Stanley Security Solutions DATE: 3/26/2015
Attn: Steven Snyder
3810 SE Naef Rd REQUESTED BY: Dianna Howse
Milwaukie, OR 97267
TRANSACTION INFORMATION:
Receipt#: 199391 Case #: ELR2015-00046
Date: 2/17/2015 Address/Parcel: 7850 SW Dartmouth St
Pay Method: CreditCard Project Name: Costco #0111
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
Permit Fee 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATU 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: y/05 By: -
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
Mar. 3. 2015 11 :23AM No. 0798 P. 1
C)
Burglar, Fire,
Security.Stsl tions . Industrial Process Alarms,
A Stanley Works Company Monitoring,
Access Control,
Closed Circuit TV
• 3810 SE NAEF ROAD MILWAUKIE, OREGON 97267 •
Facsimile Cover Sheet
To: 0.17
Phone:
Fax:- GO 1 , b 6
Prom: Steven Snyder
Stanley Security
Phone: 503-387-2912
Fax: 1-877-285-3209
Date: 3--3_ j 5
Pages including
t
C.)
his cover r page:
CAF piRNt
L L2L�116—=11 0 UU(1%
CONFIDENTIALITY NOTICE
The information contained In or attached to this telecopy transmission Is Intended only for the confidential use of the Indtvldual(e)named above. If you
are not the named recipient or an agent responsible for delivering It to the named recipient,you are hereby notified that you have received this document
In error and that review,dissemination or copying of this communication Is prohibited. If you have received this communication in error,please notify us
Immediately by telephone and return the facsimile document to us by mall. Thank you.
RECEIVED - ,s°
Electrical Permit Application FOR OFFICE USE ONLY
City of Tigard Received ,
• FEB 17 2015 DateB : sTri Permit No.: 1 ,
13!25 SW Hall Blvd., OR 97223 Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 Date/By:By:
Other Permit:
Inspection Line: 503.639.4175 CITY UH rr l( A�U Date Ready/By: Jude: @I See Page 2 for
Internet: www.tigard-or.gov ��JJ fifi Notified/Method: �G, Supplemental Information
TYPE OF0 0���"IO PLAN REVIEW
❑New construction ®Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/iteins checked below):
❑Service or feeder 400 amps or more ❑Building over three stories.
❑Demolition ❑Other:
where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
less to ground,or exceeds 14,000 ❑Commercial-use agricultural
❑ 1-and 2-family dwelling ®Commercial/industrial ❑Accessory building amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 75 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived system.
❑Addition of new motor load of ❑"A","E","I-2 "I-3",
Job no.:6292106 Job site address:7850 SW DARTMOUTH STREET 100HP or more, occupancy.
❑Six or more residential units. ❑Recreational vehicle parks.
City/State/ZIP:PORTLAND OREGON 97223 ❑Health-care facilities. ❑Supply voltage for more than
❑Hazardous locations. 600 volts nominal.
Suite/bldg./apt.no.: Project name:COSTCO#0111 ❑Service or feeder 600 amps or more.
FEE SCHEDULE
Cross street/directions to job site: Den ription I Qty. I Fee. I Total I
New residential single-or multi-family dwelling unit.
Includes attached garage.
Subdivision: Lot no.: 1,000 sq.ft.or less 145.15 4
Ea.add'l 500 sq.ft.or portion 33.40 1
Tax map/parcel no.: Limited energy,residential
DESCRIPTION OF WORK (with above sq.ft.) 75'00 2
Limited energy,multi-family
ADDTO EXISTING SECURITY SYSTEM-EDP ROOM residential(with above sq.ft.) 75.00 2
Services or feeders installation,alteration,and/or relocation
200 amps or less 80.30 2
❑ PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2
Name: 401 amps to 600 amps 160.60 2
601 amps to 1,000 amps 240.60 2
Address: Over 1,000 amps or volts 454.65 2
City/State/ZIP: Temporary services or feeders installation,alteration,and/or
relocation
Phone:( ) —7 Fax:( ) 200 amps or less 66.85 1
Owner installation:This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 401 amps to 599 amps 133.75 2
Owner signature: Date: Branch circuits—new,alteration,or extension,per panel
❑ APPLICANT ( ❑ CONTACT A.Fee for branch circuits with
above service or feeder fee,
6,65 2
each branch circuit
Business name: 13.Fee for branch circuits
Contact name:
without service or feeder fee, 46.85 2
first branch circuit
Address: Each add'l branch circuit 6.65 _ 2
Miscellaneous(service or feeder not included) _
City/State/ZIP: Each manufactured or modular 90.90 2
dwelling,service and/or feeder
Phone:( ) Fax::( ) Reconnect only 66.85 2
E-mail: Pump or irrigation circle 53.40 2
CONTRACTOR Sign or outline lighting 53.40 2
Business name:STANLEY SECURITY SOLUTIONS Signal circuit(s)or limited-
_ energy panel,alteration,or
Address:3810 SE NAEF ROAD extension.Describe: 1 Page 2 75 V 2
City/State/ZIP:MILWAUKIE OREGON 97267 Each additional inspection over allowable in any of the above
Per inspection 62.50
Phone:(503)387-2912 Fax:(877)285-3209 Investigation per hour(I hr min) 62.50
CCB Lie.: 161567 Electrical Lie.: 371054cIe Suprv.Lie.: 4783LEA Industrial plant per hour 73.75
X. 4 _ l ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: ; L L( Subtotal: 75.00•
Print name: RAY THIEMEYER Date: 02/I /15 Plan review(25%of permit fee):
State surcharge(12%ofpermit tee): 09.00
Authorized signature: ' .___._ TOTAL PERMIT FEE: 84.00
Print name: STEVEN SNYDER Date: 02/16/15 This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
* Number of inspections allowed per permit.
1.1Buitding\Permita\ELC-PemiimApp.doc 05/23/06 4404615T(OI/05/COMAVEB
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