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Permit
IIi v CITY OF TIGARD SEWER CONNECTION PERMIT t# - COMMUNITY DEVELOPMENT Permit#: SWR2015 00084 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/06/2015 Parcel: 2S104BB07900 Jurisdiction: Tigard I Site address: 14350 SW BARROWS RD 2 Project: Mathnasium Subdivision: RUSSELL'S SCHOLLS FERRY Lot: A Project Description: .5 EDU increase. Contractor: Owner: SPIRIT SPE HG 2015-1 LLC BY HAGGEN OPCO SOUTH LLC 2211 RIMLAND DR, STE 300 BELLINGHAM,WA 98226 PHONE: PHONE: FAX: FEES Description Date Amount Specifics:, Sewer Connection Fee 07/06/2015 $2,550.00 Type of Use: COM Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: .5 Total $2,550.00 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 1.800.332. Issued By: mittee Signature: Call 503. 9. 175 by 7:00 a.m.for the next available inspection date. Thls 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. • . Y TIGARD City of Tigard August 6, 2015 Hawkeye Education LLC 10650 SW Collins Ave. Portland, OR 97219 Re: Permit No. SWR2015-00084 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 14350 SW Barrows Rd #2 Project Name: Mathnasium Job No.: N/A Refund Method: ® Check#218194 in the amount of$2,550.00. ❑ Credit card "return" receipt in the amount of$ . 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): Refund 100% of sewer connection fees as fixtures capped under plumbing permit (PLM2015-00211) resulted in an EDU credit and no fees due. If you have any questions please contact me at 503.718.2430. Sincerely, "d) 0 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 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: Hawkeye Education,LLC DATE: 8/3/2015 10650 SW Collins Ave Portland, OR 97219 REQUESTED BY: Dianna Howse DA TRANSACTION INFORMATION: Receipt#: 201524 Case#: SWR2015-00084 Date: 7/6/2015 Address/Parcel: 14350 SW Barrows Rd#2 Pay Method: Check Project Name: Mathnasium EXPLANATION: Refund 100% of sewer connection as plumbing permit was revised to included capped fixtures which resulted in an EDU credit. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Sewer Connection Fee 500-0000-25500 $2,550.00 TOTAL REFUND: $2,550.00 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$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY•- Case Refund Processed: I Date: `s J By: I , ' I:\Building\Refunds\RefundRequest.doc x 09/01/2110 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV 0 ! ("'1 Ill Request for Permit Action ,p/4/i , l l(;A R n 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor 14 City Staff Check(i)one REFUND OR Name: L INVOICE TO: (Business or Individual) 11 A t..-3/4\EN t� 631-AC 4 r7 G Il� L LC Mailing Address: (p - O w Co LL i 3S ►A v__ City/State/Zip: Aa 2-rt_,q nit 02 9 7 9-1 9 Phone No.: 45:)3- c1 a.(,— Is 7,$q PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): e . 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 #: 1-)z)(2-- ,01 5- Ono g`( Site Address or Parcel#: )4 2SU `e ; /9-22_6 L,) —kt> 2- Project Name: h Ai-1 IJ S 1 LA I-1 Subdivision Name: Lot#: EXPLANATION: /AJ I rl, L L.Y ':�u5► 1 bD, t� Pi X Tc�2£E . r 1-t f iJ -RE J1 S E lit-LHA I Co �ti2r—r t--- 1 /P tLLL Of l.A2of 1.)u,,r-t iSiit Cr- G4P>p,=7 F, xi—LA 1LSc,„ 141°) .5 Li LT I t•-) -c t.L c,2i11 rs. A tJM. r-€t<,- Signature: t Date: -7//5"//5 Print Name: ---)�,ggt gbA,MS1,---,i 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 Admin: Date 711/®Qnill Route to Kecords: Date ,f�®i B x _ _Refund Processed: Date ,��© r!, Invoice Processed: Date B _ Permit Canceled: Date . /YAM B 4/j,,1 Parcel Ta: Added: Date B I:\Building\Forms\RegPerrnitAction_0923 4..oc SEWER CONNECTION PERMIT 111111 4 CITY OF TIGARD ' •. COMMUNITY DEVELOPMENT Permit#: SWR2015 00084 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/06/2015 Parcel: 2S104BB07900 Jurisdiction: Tigard Site address: 14350 SW BARROWS RD 2 Project: Mathnasium Subdivision: RUSSELL'S SCHOLLS FERRY Lot: A Project Description: .5 EDU increase. Contractor: Owner: SPIRIT SPE HG 2015-1 LLC BY HAGGEN OPCO SOUTH LLC 2211 RIMLAND DR, STE 300 BELLINGHAM,WA 98226 PHONE: PHONE: FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 07/06/2015 $2,550.00 Type of Use: COM Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: .5 Total $2,550.00 Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Spe ialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is at start:. within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the r es :dope d by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may ,btai . ..y s he rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332. . i i Issued Byi �r Permittee Signature: • 03.639.4175 by 7:00 a.m.for the next available inspectioW. This permit card shall be kept in a conspicuous place on the job site until completion of the pr'j•ct. Approved plans are required on the job site at the time of each inspection. Accumulative Sewer Tally IN Tenant Name: Mathnasium SWR# 2015-00084 Site Address: 14350 SW Barrows Rd#2 PLM# 2015-00211 Parcel#: 2S 104BB07900 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped#s value count added# added value total#s total values Baptisery/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 1 0 0 0 0 0 Dishwasher: -Commercial 4 0 0 0 0 0 -Domestic 2 0 0 0 0 0 r Drinking 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 0 0 0 -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 III') 42 0 0 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 0 0 0 0 Shower: -Gang(per head) 1 0 0 0 0 0 -Stall 2 0 0 0 0 0 Sink: -Lav/Bar-Non-Food Related 2 0 0 1 2 1 2 -Bradley S 0 0 0 0 0 -Com/Serv/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 1 6 1 6 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped F,DU Credit 0 TOTALS 0 0 0 0 2 8 _ 2 8 Current Fixture Value 8 divided by 16= 0.500 Current EDU 1 EDU= $5,100.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change 8 divided by 16= 0.500 over (under) $ 2,550.00 Enter EDU Change Here 0.500 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: Authorized Name/Signature: Branden Taggart x2449 Date: 7/6/2015 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If 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. I:\Building\Sewer Tally\Sewer I'allySheet_5100_070115.xlsx Accumulative Sewer Tally 1114 = Tenant Name: Mathnasium REVISED 7/14/15 SWR# 2015-00084 REVISED TIGA RD Site Address: 14350 SW Barrows Rd#2 PLM# 2015-00211 Parcel#: 2S104BB07900 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped#s value count added# added value total#s total values Baptisery/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 1 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 1'sye Wash 1 0 0 0 0 0 Floor Drain/Sink: -2 inch 2 0 18 36 0 -18 -36 -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 3/4 1-IP) 16 0 0 0 0 0 -Commercial(to 5 11P) 32 0 0 0 0 0 -Industrial(over 5 l IP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 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 0 0 0 0 Shower: -Gang(per head) 1 0 0 0 0 0 -Stall 2 0 0 0 0 0 Sink: -Lav/Bar-Non-Food Related 2 0 0 1 2 1 2 -Bradley 5 0 0 0 0 0 -Com/Serv/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 1 6 1 6 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit_ 0 TOTALS 0 0 18 36 2 8 -16 -28 Current Fixture Value -28 divided by 16= -1.750 Current EDU 1 EDU= $5,100.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EI)U Change -28 divided by 16= -1.750 over (under) $ (8,925.00) Enter EDU Change Here -1.750 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: 7/14/15,revised to add(18)capped fixtures(12 floor sinks&(6)floor drains) Authorized Name/Signature: Branden Taggart x2449/Debbie Adamski Date: 7/6/2015-7/14/15 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If 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. I:\Building\Sewer Tally\Sewer Tallyshect_51(X)_070115.xlsx Accumulative Sewer Tally I 'Tenant Name: Mathnasium REVISED 7/14/15 SWR# 2015-00084 1k , .i, Site Address: 14350 SW Barrows Rd#2 ,M+r 2015- 0211 Parcel#: 2S104BB07900 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped#s value count added# added value total#s total values Baptisery/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 1 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 1 0 0 0 0 0 Floor Drain/Sink: -2 inch 2 0 18 36 0 -18 -36 -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 3/4 HP) 16 0 0 0 0 0 -Commercial(to 5 HP) 32 0 0 0 0 0 -Industrial(over 5 HP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 living Unit 16 0 0 0 0 0 Oil Sep(Gas Station) 6 0 0 0 0 0 Rec.Vehide 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: -Lav/Bar-Non-Food Related 2 0 0 1 2 1 2 -Bradley 3 0 0 0 0 0 -Com/Serv/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 1 6 1 6 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 18 36 2 8 -16 -28 Current Fixture Value -28 divided by 16= -1.750 Current EDU 1 EDU= $5,100.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change -28 divided by 16= -1.750 over (under) $ (8,925.00) Enter EDU Change Here -1.750 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: 7/14/15,revised to add(18)capped fixtures(12 floor sinks&(6) floor drains) Authorized Name/Signature: Branden Taggart x2449/Debbie Adamski Date: 7/6/2015-7/14/15 Building Division Note: The property owner shall retain the ORIGINAL,sewer tally record. If 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\Sewer TallySheet_5100_070115.xlsx