Permit UPI - a
TIGARD
City of Tigard
October 8,2015
Alegis Construction
Attn: Toan Vo
6900 SW Atlanta St.,Bldg 2, Ste. 110
Portland, OR 97223
Re: Permit No. SWR2015-00093
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12196 SW Scholls Ferry Rd
Project Name: Mod Pizza
Job No.: N/A
Refund Method: ® Check#218837 in the amount of$17,238.00.
❑ Credit card"return"receipt in the amount of$ .
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): Sewer EDU credits applied from previous plumbing permits where
fixtures were capped resulted in no fees due on this sewer permit. Refund 100% of sewer
connection fees paid. See attached sewer tally sheets for EDU history.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/�AI,
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 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: Alegis Construction DATE: 10/5/2015
Attn: Toan Vo
6900 SW Atlanta St., Bldg 2, Ste 110 REQUESTED BY: Dianna Howse
Portland, OR 97223
TRANSACTION INFORMATION:
Receipt#: 201993 Case#: SWR2015-00093
Date: 8/5/2015 Address/Parcel: 12196 SW Scholls Ferry Rd
Pay Method: Check Project Name: Mod Pizza
EXPLANATION: EDU credits applied towards plumbing fixture increase resulting in no sewer fees due.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Sewer Connection Fee 500-0000-25500 $17,238.00
TOTAL REFUND: $17,238.00
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: Date: /eVefi ' By: 6 ✓ .
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT / /�/-5 'CTS''
/
q
Re uest for Permit Action
TIGARD 13125 S\V Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or gov
TO: CITY OF TIGARD
Building Division
13125 S\`V Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) NLEt-c/1 S C\c y-v;.Q.VCC1 a�i
Mailing Address: C;clrt) SvJ i-L;wN■A 7 FX/irr 110
City/State/Zip: 'PD2rt.1-Aill.)1 0f c72j
Phone No.: (;A:)`.;) q2'7
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
• • 'OID PERMIT APPLICATION.
110 - • D 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).
' � CI perm it).
Permit#: �� 7 , r LI ! ' -u/2 old/J✓-D
a'9'3
Site Address or Parcel#: 3t i1 g-0 gc0 Z .I• • /A/ S az' L LS
Project Name: MOD ►7i'Z72 A Cjt<tmof 1�t
Subdivision Name: LAZEt9s.i TEP-P SCE' Lot#:
EXPLANATION: Pitt reza, 6eS Pc - mr FMS ASS G;SS r 17ItA1
'v,15 taC -rtssvisseo lllc) y'i S RAJt (L,G,. t)
Signature: Date: e)/2y/2c/--
Print Name: ..... +', 7
ltcfund 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: Emorimuim Route to Records: Date J0fa B fie i�
Refund Processed: Date ,1r6'��ar- Invoice Processed: Date B
Permit Canceled: Date !� a /S By Parcel Tag Added: Date By
I:\Building\Forms\RegPemmitAction b9 14.•oc
CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2015-00093
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/05/2015
Parcel: 1 S134BC00200
Jurisdiction: Tigard
Site address: 12196 SW SCHOLLS FERRY RD
Project: Mod Pizza Subdivision: GREENWOOD TERRACE CONDO Lot: 17
Project Description: 3.38 EDU increase for interior TI to convert space to pizza restaurant
Contractor: Owner: ATLAS GREENWAY LLC
333 NW NINTH AVE, STE 1009
PORTLAND, OR 97209
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics:, Sewer Connection Fee 08/05/2015 $17,238.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 3.38
Total $17,238.00
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 rul: a•op -. • the Oregon Utility Notification
Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtai . copy o the rules or direct questions
to OUNC by calling 503.2 2.1987 or 1.800.332.2344.
Issued By: / iLZ Permittee Signature:
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.
Si Accumulative Sewer Tally
Tenant Name: Mod Pizza SWR# 2015-00093
Site Address: 12196 SW SchAolls Ferry Rd PLM# 2015-00241
Parcel#: 1S134BC00200
Fixture \"alue 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 (1
-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 1 4 1 4
-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 0 8 16 8 16
-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 IIP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 1 1 1 1
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 8 16 8 16
-Bradley 5 0 0 Il 0 0
-Com/Serv/Util-Food Related 3 0 0 1 3 1 3
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 3 18 3 18
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 10
TOTALS 0 0 0 23 64 23 54
Current Fixture Value 54 divided by 16= 3.375 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 54 divided by 16= 3.375 over (under) $ 17,238.00
Enter EDU Change Here 3.380 *
*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: EDU credits applied from PLM2015-00208.
Authorized Name/Signature: Dianna Howse Date: 7/30/2015
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.
1:\Building\Sewer Tally\SewerTallySheet_5100_(170115.xlsx
From: 07/28/2015 23:55 0366 P.003/0O3
Accumulative Sewer Tally
Tenant Name: MOD Pizza "`t:RI:DITS'4: SWR# N/.1
1 u�nhD
Site.\ddress: 12196 S1\'Stholls Filly Rd Y7.Mi# 2015-0020R
Parcel#: 1S134B000200
Fixture value 1'ievious Previous Credits Capped Fixture Fixture New New
# -value count capped#s value count added# added value total#s total values
Baptiser'/Font 4 0 0 0 0 0
Bath: -'J'ub/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/A'ater. 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
J ye Wash 1 0 0 0 0 0
Flout Drain/Sink: -2 inch 2 0 0 0 0 0
-3inch 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 I11') 16 0 _ 0 0 0 0
-Commercial(to 51IP) 32 0 0 0 0 0
-Industrial(over 5 I11') 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/Rar- Nun-Food Related 2 0 2 4 0 -2 -4
Bradley 5 0 0 0 0 0
-Cum!Scry/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
\\atcr lxttactmr 6 0 0 0 0 0
Water Closet-'J'oilet 6 0 1 6 0 -1 -6
t
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
101,\1-S 0 0 _ 3 _ 10 0 0 _ -3 -10
Current Fixture\'aloe -10 divided by 16= -0.625 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16_ 0.000 Previous EDU
Change -10 divided by 16 e -0.625 over (under) S (3,213.00)
Enter EDU Change Here -0.630
Notes: "''CREDITS "
Authorized Name/Signature: Debbie \damski Date: /2/2015
Building Division
Note: 'Die property owner shall retain the OR1GIN.11.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:\lJuilding\Sewer'rally\Scu•t r l'ally Sheet_491X1._IAu114\l>\