Permit voi �
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 8
Request for Permit Action ��
q �,L
l CI n R n 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • �n� .tlgard-or.gov,
TO: CITY OF TIGARD �,�� t���',Q�
Building Division V �`�GD
13125 SW Hall Blvd.,Tigard,OR 97223 '��1L
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner Rs Applicant a Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: �J
INVOICE TO: (Business or Individual) a.a - // h 4 047
Mailing Address: PC, ,` J' 7ca/
City/State/Zip: 9 72 5
Phone No.: _5'63- aG- 5,86
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Er CANCEL/VOID PERMIT APPLICATION.
0�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 #: /Win 75-- C ej )q
Site Address or Parcel#: /6)-5'o sr,. geb
Project Name: Gem Se i.. fLk.a 4 w y
Subdivision Name: Lot#:
EXPLANATION: C c 1 S
Signature: Date: /0 -/y-/
Print Name: to A.6
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 7.9-570°/(c'
3. Please allow 3-4 weeks for processing refund requests. 3 7 5-, 9 - r.l o o .
y� es -- 3�, o a = -
3_3 6• -2 (FY- 07
FOR OFFICE USE ONLY
Route to S s Admin: Date !o'Q,7, i L.-4_b Route to Records: Date ( Amin B
Refund Processed: Date // 9 /5 By -01; Invoice Processed: Date By
Permit Canceled: Date 94 t ' By its• Parcel Tag Added: Date By
I:\Building\Forms\RegPerrnitAction_p!2314.doc
kg 41613-1
«x
City of Tigard
November 19, 2015
Dean Warren Plumbing
Attn: Joe Raab
PO Box 14701
Portland, OR 97293
Re: Permit No. PLM2015-00342
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16290 SW Upper Boones Ferry Rd
Project Name: Oregon Treasury
Job No.: N/A
Refund Method: ® Check #219202 in the amount of$336.25.
❑ Credit card"return" receipt in the amount of$
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
U
: 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: Dean Warren Plumbing DATE: 11/06/2015
Attn: Joe Raab
PO Box 14701 REQUESTED BY: Dianna Howse
Portland, OR 97293
TRANSACTION INFORMATION:
Receipt#: 202911 Case #: PLM2015-00342
Date: 10/07/2015 Address/Parcel: 16290 SW Upper Boones Ferry
Pay Method: CreditCard Project Name: Oregon Treasury
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
..REF �
UND
- - _- .p-.:r-.�'. - - .:F:"'_2'..Y.,..f:, __
ee escti rion.From
'�Reveniie"AccountN
;m
e .Buildul Permtt Fee ,.-�_ t>� -
..
Plumbing Permit Fees 230-0000-43101 $300.23
12% State Surcharge 100-0000-24001 36.02
TOTAL REFUND: $33623
APPROVALS: SIGNATURES/DATE:
If under$3,000 Professional Staff ) i (.2—X
If under$12,500 Division Manager
If under$23,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
M ADMINISTRATION USE=ON
Case Refund Processed: Date: l /.17�s By:
1`_\Building\Refunds\RefundReyuest.doc x 09/01/2010
r, CITY OF TIGARD PLUMBING PERMIT
II 1 ' COMMUNITY DEVELOPMENT Permit#: PLM2015-00342
T WARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/07/2015
Parcel: 2S113AB01201
Jurisdiction: Tigard
Site address: 16290 SW UPPER BOONES FERRY RD
Project: Oregon Treasury Subdivision:COUNCIL VIEW ACRES(LOTS 21-44) Lot: 30
Project Description: Interior plumbing:Capping(9)2"floor drains;Adding(1)shower stall;Relocating(1)2"floor sink,(1)3"floor sink,
(2)sinks;Installing(1)water heater.
Contractor: DEAN WARREN PLUMBING& REMODELING INC Owner: PACIFIC REALTY ASSOCIATES LP
PO BOX 14701 ATTN: N PIVEN
PORTLAND, OR 97293 15350 SE SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-236-4152 PHONE:
FAX: 503-296-2218
FEES
Quantity Description Date Amount
9 ea Fixture/Sewer Cap 10/07/2015 $225.18
Specifics: 2 ea Floor Drain/Floor Sink/Hub 10/07/2015 $50.04
2 ea Sink 10/07/2015 $50.04
Type of Use: COM 1 ea Tub/Shower/Shower Pan 10/07/2015 $12.51
Class of Work: ALT 1 12%State Surcharge- 10/07/2015 $45.03
Type of Const: Plumbing
Occupancy Grp: 1 ea Water Heater 10/07/2015 $37.52
Stories:
Total $420.32
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.:
Issued By: _� ./% - ••••lure: /, ,
Call 50 .639.4175 by 7:00 a.m.for the next available inspecti• 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.
Plumbing Permit Application GD It a jj
Building Fixtures ece`\1 FOR OFFICE USE ONLY
City of Tigard vi 9 Received Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 OC,1 ^�D Date By: `Q ] � - g rnp0(�a)3L(�
II Phone: 503.718.2439 Fax: 503.598.1960 f t,GP O lam Review
ate/By: Other Permit No.:
T I G A R D Inspection Line: 503.639.4175 C!1 QO O OW' Date Ready/By: Juris: ® See Page 2 for
Internet: www.tigard-or.gov gO�r1 ,N Notified/Method: Supplemental Information
TYPE OF WORK 1• FEE* SCHEDULE
El
construction ❑Demolition For special information use checklist.
Description Qty. Ea. I Total
Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) _
CATEGORY OF CONSTRUCTION SFR(I)bath 312.70
El I-and 2-family dwelling '*Commercial/industrial SFR(2)bath 437.78
El Accessory building SFR(3)bath 500.32
g ❑ Multi-family
Each additional bath/kitchen 25.02
El Master builder El Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
1 Catch basin or area drain 18.76
Job site address: /(�),�iG' cad 1pe-�-��.�-,
Dtywell,leach line,or trench drain 18.76
City/State/ZIP: Ii 15-)-t4_ _ q 77 )-9 Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: Project name: CIY‘a. i- 4/ti Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF WORK Backwater valve 12.51
Clothes washer 25.02
7-47 Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
❑ PROPERTY OWNER ❑ TENANT Expansion tank 12.51
Name: Pc/2 Frei, Fixture/sewer cap 25.02 X 25�J 0
` 1 - Floor drain/floor sink/hub Ir6t. a 25.02 - ,��piy Address: /5-3 SZj 6w S y a J- J / , /
Garbage disposal 25.02
City/State/ZIP: --,•S y(.( op, '3 2 l i it Hose bib 25.02
Phone:(1-9 ) 61.y_6 3 GC Fax:( ) Ice maker 12.51
El APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02
J /� Medical gas(value:$ ) Page 2
Business name: /9.,cji. C..V�.yr -.-tt ,h "",( � °(,/
f Primer 12.51
Contact name: 3. -c_e Roof drain(commercial) 12.51
Address: /9 c
X.SCj,_ )1,./`/ ./ Sink/basin/lavatory ,-�4,,c, � ' 25.02 7".o q
City/State/ZIP: ��r7 h l 9 3 Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan 0,4c/i1^› / 12.51 /.2-,51
E-mail: Urinal 25.02
CONTRACTOR Water closet 25.02
Water heater /- 37.52 3 7.7r-2--
Business name:
,i e,th e"-tom) Water piping/DWV 56.29
Address: Other: 25.02
City/State/ZIP: Subtotalr37C
Phone:( ) Fax:( ) Minimum pennit fee: $72.50
Plan review (25%of pennit fee)
CCB Lie.: /S1,f) Plumbing Lic.no.:16_73 6 O0 ��f/,�-^
State surcharge(12%of permit fee)'7 -5 •0,
Authorized signatu 74/1" TOTAL PERMIT FE
Print name: 4 -C Date:/t.`J•-rj_/5 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I Building\Pelmits:PLMU-PermitApp.doc 10,01'09 440-46t6T(10/02:COM'WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Suppression Systems:
Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee:
Footing drain- I, 100. 50.03 0 to 2,000 S121.90
Footing drain-each additional 100. 37.52 2,001 to 3,600 $169.69
S 3,601 to 7,200 $233.20
Sewer 1st 100' 62.54
7,201 and greater $327.54
Sewer-each additional 100' 37.52
Water Service-1st 100' 62.54 Medical Gas Systems:
Water Service-each additional 100' 37.52
Valuation: Permit Fee:
Storm&Rain Drain-1st 100' 62.54
S I.00 to$5,000.00 Minimum fee S72.50
Storm&Rain Drain-each additional 100. 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for
Other Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to
I� and including$10,000.00.
Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for
which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to
(minimum charge-1/2 hour) and including$25,000.00.
Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for
hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to
Reinspection Fees 90.00/hr and includingS50,000.00.
Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for
(minimum charge-1/2 hour) each additional$100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added Relocate
❑ Any new commercial building with water service 2"and
Baptistry font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower
-Jacuzzi/Whirlpool engineer.
Car Wash: Each Stall ❑ New exterior plumbing site utilities for any complex structure
Drive tall as defined in OAR918-780-0040.
Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities.
Dishwasher: Commercial ❑ Any multipurpose fire sprinkler system.
Domestic ❑ Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
/ = Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2" f,
It / Isometric or Riser Diagram
❑ Isometric or riser diagram is required for new buildings
-Car Wash Drain
Garbage Domestic non-food that meet the qualifications above.
Disposal: -Domestic food related
-Commercial food related
-Industrial food related
Ice Mach./Refrig.Drains Comments regarding fixture work:
Oil Separator(Gas Station)
Rec.Vehicle Dump Station
Shower: -Gang
-Stall r
Sink: -Lay/Bar non-food related
-Bradley
-Com/Serv/Util food related
-Service *Note: If the fixture work under this permit results in an
Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and
Washer-Clothes fees assessed for the sewer increase must be paid before the
Water Extractor
Water Closet-Toilet plumbing permit can be issued.
Urinal
Other Fixtures:
I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2
Accumulative Sewer Tally
11111 B . Tenant Name: ORI:.GON TREASURY SWR# N/A
ric,nkn Site Address: 16290 SW UPPER BOONES FERRY RD PLM# 2015-00342
Parcel#: 2S113AB01201
Fixture Value Previous Previous Credits Capped I i\nur 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 l 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 9 18 0 -9 -IS
-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 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.Vehicle Dump station 16 0 _ 0 0 0 0
Shower: -Gang(per head) 1 0 0 0 0 0
-Stall 2 0 0 1 2 1 2
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-Bradley 5 0 0 0 0 0
-Com/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
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS ALS 0 0 9 _ 18 1 2 _ -8 -16
Current Fixture Value -16 divided by 16 = -1.000 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -16 divided by 16= -1.000 over (under) S (5,100.00)
Enter EDU Change Here -1.000 *
*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: ***CREDIT***
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 10/7/2015
Building Division
suote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
bmitted 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