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City of Tigard • COMMUNITY D fL 'MhNT13PARTMENk:11 i'� �r
:1111111 W Request for Permit Action BUILDIN�p�ij��
i c;Aur.. 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •wvtnv.tig�.rd-or,g'ov ��
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigatdBuildingPermits@tigard-or.gov
FROM: ❑ Owner Q Applicant Contractor ❑ City Staff
Check(✓)une
REFUND OR Name: r <r rS,� Y 1�.
INVOICE TO: (l;ustncss or Individual) C` v( I�-
Mailing Address: ) -5 /st-) 4J V�.-
City/State/Zip: c"--1-76.114\ c4 # _ (]� CL /OA'7Phone No.: 5O 92c12 %-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
CANCEL/VOID PERMIT APPLICA'T'ION.
[] REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
• INVOICE FOR PEES DUE(attach case fee schedule and provide explanation below).
[] REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: c •. • - 0 b
Site Address or Parcel : '7& O (t} t (• �( /50
Project Name:
Subdivision Name: [ es4- 1''k) I..ot#:
EXPLANATIO : P LA- tAJs t lex- 04li e-c
Signature: ate_ T Date: 5-/ _/(p
Print Name: (mge&--0-40CA2L_
Riefnrnrl Policy
1 The ciry's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid ur collected.
• Nor more than 80%of the application or plan review fee when An application is withdrawn or canceled before review effort
has been expended.
• Nut mute than 130%of the application or permit fee for issued permits prior to any inspection requests. / �j 0
1 All refunds will be returned to the original payer in the form of a check via US postal service. r /
3. Please allow 3-4 weeks for processing refund requests. «[' ra
/G. •y — ,�/ , i 3, 23
/So, 60? /a? 0- ..3o ,/3--
FOii OFFICE CSE ONLY
Route to Sys Admin; Date /Mir By J% Route to Records: Date ffl nrik•.'
Refund Processed: Date /3 /(o :'`?� Invoice Processed: Date By
Permit Canceled: Date _1/3/ /t/, By • Parcel lag Added: Dare By
t:\.Building\Forme\Ra Purn iLAcuon_U9_dd314,•oc
.1111 um
TIGARD
City of Tigard
April 13, 2016
AFP Systems Inc.
Attn: Karmen Carlson
19435 SW 129th Ave.
Tualatin, OR 97062
Re: Permit No. FPS2015-00145
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7500 SW Dartmouth St., #190
Project Name: Which Wich
Job No.: N/A
Refund Method: ® Check#220624 in the amount of$120.49.
❑ Credit card "return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account"deposit" receipt in the amount of$
Comment(s): Per applicant's request as project was completed by another contractor.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
i
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: AFP Systems Inc. DATE: 3/31/2016
Attn: Karmen Carlson
19435 SW 129th Ave REQUESTED BY: Dianna Howse
Tualatin, OR 97062
TRANSACTION INFORMATION:
Receipt#: 202558 Case #: FPS2015-00145
Date: 9/14/2015 Address/Parcel: 7500 SW Dartmouth St, #190
Pay Method: Check Project Name: Which Wich
EXPLANATION: Per applicant's request as project was completed by another contractor. Refund 80% of
permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. • Refund
Example: Building Permit Fee . Example: 2300000-43104 $Amount
Building Permit Fee 230-0000-43104 $107.58
12% State Surcharge 100-0000-24001 12.91
TOTAL REFUND: $120.49
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff r
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: !�/3//{o By: .415;44--
1.\Building\Refunds\RefundRequest doc
415;T1:\Building\Refunds\RefundRequest.doc s 09/01/2010
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
i = COMMUNITY DEVELOPMENT Permit#: FPS2015 00145
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/23/2015
Parcel: 25101 BA00101
Jurisdiction: TIGARD
Site address: 7500 SW DARTMOUTH ST 190
Project: Which Wich Subdivision: WEST PORTLAND HEIGHTS Lot:
Project Description: Add(6)new upright sprinkler heads,(20)new sprinkler head drops,(2)new dry heads in cooler/freezer all of
existing wet system to cover new tenant space.
Contractor: AFP SYSTEMS INC Owner: WAL-MART REAL ESTATE BUSINESS TR
19435 SW 129TH AVE BY PROPERTY TAX DEPT STORE 5935-00
TUALATIN, OR 97062 PO BOX 8050
ATTN MS 0555
BENTONVILLE,AR 72716
PHONE: 503-692-9284 PHONE:
FAX: 503-692-1186
FEES
Description Date Amount
Specifics: Plan Review-Fire Life Safety-COM 09/14/2015 $229.08
Type of Use: COM
Class of Work: ALT Type of Const:
Occupancy Grp: A-2 Height: ft
Stories: 1
Commercial Sprinkler System:
Sprinkler Required: Yes Sprinkler Type: Wet
Standpipe Required: No Hazard: ORD1
Density: .2 Design Area: 1500
K Factor: 5.6
Commercial Fire Alarm System:
Fire Alarm Required: Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $229.08
•
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $5,250.00
Residential Square Footage: 0
Fire Alarm Valuation: $0.00
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 11(10.3a2.2344.
Issued By: Permittee Signature: 1
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.
Building Permit Application RECEIVED
Fire Protection System I•OR(HI 1( 1: 1 ,,I O\I.1
City� of Tigard SEP 1 4 2015 RDeacteeBiveyd: 9 4;2(7,, Permit No. 05',*/s ety
j
1111 I " 13125 SW Hall Blvd.,Tigard,OR 97223,8 Plan Revie ► ir, / - ether Pe 's
Phone: 503.718.2439 Fax: 503.598.1 TYOFTIGARL) Date/ ,`J J �, - //5—t:7/o2 •
T I G A R D Inspection Line: 503.639.4175 B t J 1LD1NC htvi S10 r Date Ready/By. ® See Page 2 for
Internet: www.tigard-or.gov 1 Notified/Method: / rth- MI, Supplemental Information
t �(r� ,
TYPE OF W ii ° ' REQUIRED DATA 1-AND 2-FAMILY DWELLING
❑New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
®Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
El 1-and 2-family dwelling Valuation: $
y g ®CommerciaUindustrial
❑Accessory building ❑Multi-family Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address:7500 SW Dartmouth St. New dwelling area: square feet
City/State/ZIP:Tigard,OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no,91—/it 0 Project name:Which Wich Covered porch area: square feet
Cross street/directions to job site:Retail Bldg.#2 Deck area: square feet
Other structure area: square feet
REQUIRED DATA COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: Permit fees*are based on the value of the work performed.
Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Add 6 new upright sprinkler heads-20 new sprinkler head drops Valuation: $$5,250.00
2 new dry heads in cooler/freezer all off of existing wet system Existing building area: square feet
to cover new floor plan New building area: square feet
❑ PROPERTY OWNER I Number of stories: 1
Name: Type of construction: V-B
Address: Occupancy groups:
City/State/ZIP: Existing: M
g�
Phone:( ) Fax:( ) New: B-business
® APPLICANT 0 CONTACT PERSON llICo 4A _ % ve.4 Ni lv Y lui 4.4r,
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed.If the
City/State/ZIP: applicant is exempt from licensing,the following reasons
apply:
Phone:( ) Fax::( )
E-mail:april @afpsys.com
CONTRACTOR BUILDING PERMIT FEES*
Business name:AFP Systems Inc. (Please rejerto fee schedule)
Permit fee:
Address:19435 SW 129th Ave.
State surcharge(12%of permit fee):
City/State/ZIP:Tualatin,OR 97062 0
FLS plan review(40%of permit fee): .r)
Phone:(503)692-9284 Fax:(503)692-1186 (Due upon application submittal.) if a 9 t 0
CCB lic.:67534 Total permit fees:
Amount received:
Authorized signature:
This permit application expires if a permit is not obtained
Print name:Steve Frost Date:9/14/2015 within 180 days after it has been accepted as complete.
* Fee methodology set by Tri-County Building Industry
Service Board.
1:Building\Permits\FPS-PermitApp_071514.doc 440-4613T(11/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2- Supplemental Information
Describe work to be done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
❑ New system Number of sprinkler heads: 28 Number of alarm devices:
® Addition or ❑ 1-10 heads: Affidavit required and ❑ 1-5 devices: Affidavit required and
Alteration (3) copies of sketch showing area (3) copies of sketch showing area
to existing of work within building structure of work within building structure
system
® 11+ heads: Plan review required and El 6+ devices: Plan review required and
(3) sets of plans. (3) sets of plans.
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
® \Vet ❑ Dry
Additional Standpipes none
Information: Hazard Group OH 1
Density 0.20
Design Area 1500
K. Factor 5.6
Sprinkler Project Valuation: $ 5,250.00
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations ❑ Yes
include: Individual Component El Yes
Cut Sheets
Fire Alarm Project Valuation: $
D.) Residential Sprinkler(Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A,B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12%of permit fee): $
FLS Plan Review(40% of permit fee): $
TOTAL: $
F:\Steve\Prints TI\walmart out bldg 2\which wich FPS_PermitApp.doc 2
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
;1 Request for Permit Action
r,(;A R i 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 ERity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) gf/49- 11° YS TE S
Mailing Address: /9 "3-� SGO /02 9 '`- ff v'c
City/State/Zip: 7' U4 l9 Tin/ e 2 920(0.2.,
Phone No.: -5-03 - 6 902 - 9a�y
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑ CANCEL/VOID_ PERMIT APPLICATION.
REF'U ERMIT FEES (attach copy of original receipt and provide explanation below).
E FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: / -/"S.020/S - rD/y-5"
Site Address or Parcel#: 750-0 .G(J2/p.�%/`10 i 77/ /2 Q
Project Name: 0/bet/ 24} Glf
Subdivision Name: Lot#:
EXPLANATION: A dyC6Z v°,1`7"16---A/
cc 770 Al `A/ 20.T&---e_r £4 -1 9- 77o.f ,
Signature: z�j,O- � Date: /2-,3/, 5'
Print Name: 24!1„/N,14 / 47'JE—
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 Sys Admin: Date By Route to Records: Date By ,4744---
Refund Processed: Date /,2//Q /s By o h Invoice Processed: Date By
Permit Canceled: Date ,//f By .1,!m, '. cel Tag Added: Date By
I:\Building\Forms\RegPemutAction_09Z314.doc
i
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City of Tigard
December 10, 2015
• AFP Systems
19435 SW 129th Ave.
Tualatin, OR 97062
Re: Permit No. FPS2015-00145
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 7500 SW Dartmouth St, #190
Project Name: Which Wich
Job No.: N/A
Refund: ® Check#219444 in the amount of$17.67.
❑ Credit card "return" receipt in the amount of$
❑ Trust account "deposit" receipt in the amount of$
Notes: Refund of overpayment of permit fees due to reduction in project valuation.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
1:\suiiding\Refund,� t o .aebriY'Ate paTj 6141 egon 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_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: AFP Systems DATE: 12/3/2015
19435 SW 129th Ave.
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
TRAiNSACTION INFORiMATION:
Receipt#: 202558 Case#: FPS2015-00145
Date: 9/14/2015 Address/Parcel: 7 500 SW Dartmouth #-190
Pay Method: Check Project Name: Which Wich
EXPLANATION: Refund overpayment of permit fees due to reduction in project valuation.
REF..IJN.D INF ORMATION.- -- _ - - -_..,.- ^zr:. ;.. -.-__ .41 - •-�-�-�,. -..
:
No 'Sr
'Refiirid'
'cc"'unf4
"t' �%. =ReveriueA o �-
rFee Descri tiori'F'rom'Rece ., :
';T �2"00000=43'104�=� �•Anoiin xample::=Butldm�Pemut Feer-__ . . - . .-_.- . _. �;�• ::-:,. , Esarnp e .. 3 . . ... ... ..... ..�-$
Cash Over 100-0000-48001 $17.67
TOTAL REFUND: $17.67
APPROVALS: SIGNATURES/DATE:
IE 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
TIDEMARK SYSTEMADMINISTRATION:USE:ONLY.; r;<<<; '
Case Refund Processed: Date: /c//d//_c By: 4-
I:\Building\Refunds\RefundReguest.doc x 09/01/2010