Permit City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMEN it:. � E 11 -
: Re uest for Permit Action
q 1 I, ,,,,i; 1 , 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigarr�'olr. X •
1,11
TO: CITY OF TIGARD
BUILDING Q VI IO
Building Division �Io�
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 0 / ef ` ^ 1 CO^/ 5;10 C
Mailing Address:
X 35 A4)15 P
City/State/Zip: 0 k A e 1 icJ F Q kQ ?7// 3
Phone No.: QQ 3- a t7 -75'7 lc
PLE' SE TAKE ACTION FOR THE CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
I INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: 'Hie__ 9-0 ( 6--O U 7,/
Site Address or Parcel #: (D'i 37 (C 1 1 (per= 4 O
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Si-
Name: v} Fr
Subdivision Name: Lot#:
EXPLANATION: o___.1 ot.Q Q c.K 1 ,.,,..
,_ Ak,„ . Fs,,AA.._ _I— ../Lote..,,LA.,__.a,
Signature: ��../ 0.,4, - Date: 10 2, V
Print Name: ra
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 90.oV - 7a .of = /eft• 0-0
/O .h ) ce". 6y = / (2
/00,6e0
- 8 , 6 ' - .2-0,/e•
FOR OFFICE USE ONLY
Route to S s Admin: Date to fSMIL R� M Route to Records: Date /jMEIN B oir,-Z
Refund Processed: Date / 1S By 1; (( Invoice Processed: Date By
Permit Canceled: Date // F//S By /%ind ',reel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0'12314.doc
III
:FMGARD
City of Tigard
November 19, 2015
Holmes Installation Service
Attn: Ray Flanders
33535 NW Vadis Rd
Cornelius, OR 97113
Re: Permit No. MEC2015-00731
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12537 SW 116th Ave.
Project Name: Neff
Job No.: N/A
Refund Method: ® Check#219211 in the amount of$80.64.
❑ Credit card "return" receipt in the amount of$ .
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 permit was not required (gas line already in
place). Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
f ei--e_.__�
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
711
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 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: Holmes Installation Service DATE: 11/06/2015
Mtn: Ray Flanders
33535 NW Vadis Rd REQUESTED BY: Dianna Howse
Cornelius, OR 97113
TRANSACTION INFORMATION:
Receipt#: 400336 Case #: 1,1EC2015-00731
Date: 10/28/2015 Address/Parcel: 12537 SW 116th Ave
Pay Method: CreditCard Project Name: Neff
EXPLANATION: Per applicant's request as no permit was required (gas line already existed). Refund 80%
o
of permit fees.
,REFUND INFORMATION:
Description From'Recei t = Revenue"AccountNo:_= s':" ="Refund:a
P. -
-r ... .:.. -..._.:...
Exam le: Buddui Permtt:Fee { _ ";'``
Mechanical Permit Fee 230-0000-43102 $72.00
12% State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATL.IRES/DATE:
If under$5,000 Professional Staff A
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
__ F.OR TIDEMARK SYSTEM ADMINISTRATION USE_ONLY==T -::= - '.`% :='=:`
Case Refund Processed: Date: //`/P7s By: /4 .. • _._ _
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
�f� F'"' CITY OF TIGARD
MECHANICAL PERMIT
.n y
ipil
F COMMUNITY DEVELOPMENT Permit#: MEC2015-00731
I f ;'�" Date Issued: 10/28/2015
TIGARD 13125 SW Hall Blvd,Tigard OR 97223 503 718 2439
Parcel: 2S103BD04900
Jurisdiction: Tigard
Site address: 12537 SW 116TH AVE
Project: NEFF Subdivision: HUNTER'S GLEN Lot: 5
Project Description: Installing gas piping for a gas range
Contractor: HOLMES INSTALLATION SERVICE Owner: NEFF, JAN & SHERRI
33535 NW VADIS RD 12537 SW 116TH AVE
CORNELIUS, OR 97005 PORTLAND, OR 97223
PHONE 503-647-9320 PHONE
FAX
FEES
Specifics: Description Date Amount
Fuel Piping 10/28/2015 $14 15
Type of Use: SF 12%State Surcharge-Mechanical 10/28/2015 $10 80
Class of Work: ALT Type of Const• Minimum Fee Adjustment-Mechanical 10/28/2015 $75 85
Occupancy Grp:
Stories:
Fuel
Fuel Types
Gas Pressure
Total $100 80
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- 090 You may obtain a copy of the rules
or direct questions to OUNC by calling 503 232 19; or 1 800 3 •4 0:A‘Gk-s---
Issued By: Permit ee 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.
Mechanical Permit Application e FOR OFFICE''USE Or ti : . -
City of Tigard Received Permit No s f
° 13125 SW Hall Blvd.,Tigard,OR 97223
Date/By s an A -G- II
g Plan Review
Phone 503.718 2439 Fax. 503 598 1960 Date/By Other Permit
x Inspection Line 503 639 4175
T
ON f GA K D; Date Ready/By ® See Page 2 for
Internet www.tigard-or.gov 0 Notified/Method Supplemental Information en
T E O OR �� \(5‘ COMMERCIAL FEE* SCHEDULE — USE CHECKLIST
Q .c\-...\\\S.-� Mechanical permit fees*are based on the value of the work
❑New construction Addition/alteration/reel ,4i ei } performed.Indicate the value(rounded to the nearest dollar)of all
❑Demolition ❑Other: mechanical materials,equipment,labor,overhead,and profit.
Value $
CATEGORY OF CONS'ION RESIDENTIAL EQUIPMENT/SYSTEMS FEES*
ts
1-and 2-family dwelling ❑Commercial/industrial Accessory building For special information use checklist.
Multi-family 11 Master builder ❑Other: Description Qty. Ea. Total
JOB SITE INFORMATION AND LOCATION Heating/cooling:
L ?-' -3 7 ct .s
Air
Job Site address' V' 1 Au (requires site plan showing placement) 46.75
City/State/ZIP: 4 4, �. Furnace 100,000 BTU(ducts/vents) 46 75
Furnace 100,000+BTU(ducts/vents) 54.91
Suite/bldg./apt.no.. Project name: Heat pump
(requires site plan showing placement) 61 06
Cross street/directions to job site: Duct work 23 32
Hydronic hot water system 23 32
Residential boiler(radiator or
hydronic) 23 32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc 46 75
Subdivision: Lot no.: Flue/vent for any of above 23 32
Other 23.32
Tax map/parcel no.: Other fuel appliances:
DESCRIPTION OF WORK Water heater 23.32
j/ y— Gas fireplace 33.39
j u "C," f etsie f /7)/2 4 e._. Flue vent for water heater or gas
fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23 32
PROPERTY OWNER El TENANT Chimney/liner/flue/vent 23 32
// t „�� Other 23 32
Name: 51,a�v`r (,,.)r/�! ��'� Environmental exhaust and ventilation:
{` �Z C 5� ( ®�._ Range hood/other kitchen
Address: 7 7/b PT
equipment 33.39
City/State/ZIP:7—t Cr ,--) c3 L•E_ Clothes dryer exhaust 33 39
l. Single-duct exhaust(bathrooms,
PhoneV3) tf— 27 6 Fax:( ) toilet compartments,utility rooms) 23 32
El APPLICANT ❑ CONTACT PERSON Attic/crawlspace fans 23 32
Business name: Other 23 32
Fuel piping:
Contact name: $14.15 for first four;$4.03 for each additional
Furnace,etc.
Address: --
Gas heat pump
City/State/ZIP: Wall/suspended/unit heater
Phone:( ) Fax::( ) Water heater
Fireplace
E-mail: Range
CONTRACTOR Barbecue
Busin e:V. e S fi 7 J c (I tom'"r i✓ Se AA C -Q_ Clothes dryer(gas)
7` 3 m� V� ` 5 ,�n Other
Address: j 7 1 rG�/1 MECHANICAL PERMIT FEES*
City/State/ZIP: (0 vA e_ 1(,/t' ® ve_ 7 7/1 $ Subtotal
r Minimum permit fee($90.00)
Phone: Fax:( ) Plan review(25%of permit fee)
CCB lic.: J co 02 ..(' 7 3 State surcharge(12%of permit fee)
�J TOTAL PERMIT FEE
gn , �/�/f—f�/p.L"� jG�L� This permit application expires if a permit is not obtained within 180
Authorized signature: /'2(.L " / days after it has been accepted as complete.
Print name: WA /a& �)er5' Date: /0. 2� / * Fee methodology set by Tri-County Building Industry Service Board
1\Building\Permits\MEEC-Pe ItApp doe 09/09/10 440 617T(I1 2/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial & Multi-Family Fee Schedule:
Total Valuation: Permit Fee:
$0.00 to$500.00 Minimum fee$69.06
$500.01 to$5,000.00 $69.06 for the first$500.00 and
$3.07 for each additional$100.00 or
fraction thereof,to and including
$5,000.00.
$5,000.01 to$10,000.00 $207.21 for the first$5,000.00 and
$2.81 for each additional$100.00 or
fraction thereof,to and including
$10,000.00.
$10,000.01 to$50,000.00 $347.71 for the first$10,000.00 and
$2.54 for each additional$100.00 or
fraction thereof,to and including
$50,000.00.
$50,000.01 to$100,000.00 $1,363.71 for the first$50,000.00 and
$2.49 for each additional$100.00 or
fraction thereof,to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first$100,000.00 and
$2.92 for each additional$100.00 or
fraction thereof.
Note: All new commercial buildings require 2 sets of plans. .
I:\Building\Permits\MEC-PermitApp.doc 09/09/10 2