Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
0
Request for Permit Action
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 City Staff
Check(✓)one
REFUND OR Name: r
A
INVOICE TO: (Business or Individual) /V
Mailing Address: /T
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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 #: E)w P-001 5-00 15,:5
Site Address or Parcel#: 99-75 &-z, loiQf-W i tia i-r #�p go
Pro)ect Name: Ji Tsc'T� T1£7� L'R L �o2euP
Subdivision Name: Lot #:
EXPLANATION: dw tit �/�J j;� �w 2 C2 tin T Voce fffe.
�ouc l2 EACLes grbc �e we�2 A�eM
""--''o0 397
Signature: �r�a.-C_ Date: / /7//
Print Name: lqbf*rA-'5k)
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Ach in: Date/jl 7 I,5- Route to Records: Date Z y / B
Refund Processed: Date A/ B Invoice Processed: Date B
Permit Canceled: Date/ / B Parcel Ta ridded: Date B
1:\Building\Forms\RegPemvtAction_0 2314. oc
Plumbing Permit Application f0 - 1.
Building Fixtures FOR OFFICE USE ONLY
ti•
City of Tigard ` AN Received /� � _
Date/BV: /5- /,q7 Permit No.: 7
■ 13125 SW Hall Blvd.,Tigard.OR 97223 `•+
,{ Plan Review
Phone: 503.713.2439 Fax: 503.593.0; 15'", ,� Date/Bv: Other Permit No. �S
Inspection Line: 503.639.4175 6y
' Date Ready/Bv: Juris: ® See Page 2 for
Internet: w'ww.tigat'd-or.gov .� Notified/Method: /.• Supplemental Information
TYPE"OF WORK N� ". FEES SCHEDULE_ -
^New construction ❑ Deniolitio�\j�3 � "�N1' For special information use checklist.
Desch tion Qty. I Ea. Total
iAddition/alteration/replacement ❑ �
Other: i New I-2-family dwellings(includes 100 It.for each utility connection)
CATEGORY OF CONSTRUCTION. '� SFR(1)bath 313.70
❑ I-and 2-family dwelling Connmercial/industrial SFR(2)bath 437.73
SFR(3)bath 500.32
❑ Accessory building ❑Multi-family
Each additional bath/kitchen 25.02
❑ Master builder ❑Other: Fire sprinkler( sq. ft.) Pase 2
-JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: Catch basin or area drain 13.76
Drywell,leach line,or trench drain 13.76
City/State/ZIP: �? _ 0 2-7
Footing drain(no.linear It.:_) Page 2
Suite/bldg./apt. no.: Project name: /
e-4 ci--1 S i2 lanulactured home utilities 50.03
Cross street/directions to job site: Manholes 13.76
Rain drain connector 13.76
Sanitary sewer(no.linear ft.: ) Pa,2e 3
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear Il.:_) Page 2
Subdivision: Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
DESCRIPTION OF-WORK Backwater valve 12.51
1 Clothes washer 25.03
LLZ,s Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Expansion tank 12.51
OWNER.','�. - -:❑;'TENANT�`f,','.' " Exp"
Name:
Fixture/sewer cap 2 5.02
Address:
�1 , Floor drain/floor sink/hub 25.02
) l��
City/State/ZIP:
Garbage disposal 25.02
-�
/ � 07� Hose bib 25.02
i
Phone: ( ) Fax:( ) tee maker 12.51
❑ '"F 1PLICANT ❑, CONTACT :PERSON Interceptor/grease trap 25.02
Business name: Medical gas(value:S 1 Page 2
Contact name: Primer 1251
Roofdrain(commercial) 12.51
Address:
Sink/basin/lavatory � 25.02 ��,Zj,iG)
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: ;( ) Tub/shower/shower pan 13.51
E-mail: Urinal 25.02
CONTRACTOR- '_ Water closet 25.02
Water heater j 37.52 37, SA
Business name: M• n �L(( ' Waterpiping/DWV 56.29
Address: SCJ �1j` I C Other: 25.02
City/State/ZIP: U nGU c�s� -✓t>4 �a6�Z Subtotal
E
e: '-,6a ) Fax;( ) Minimum permit fee: 572.50 16i, ,Z f l-t Lic.: �7�7 Plumbin-Lic.no.: j�j3 1f 3 U Plan review (25%ofpennit fee)
State surcharge(12%of permit fee)
Authorized signature: - TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within HO[lays
Print name: L�✓�) tnn, (� L (y_ Date: �� 7vf after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
l:Building•Permits4'Lxt U-PemiitApp.doc 1001.09 440-4616T(10,02,CO\BWEB)
Accumulative Sewer Tally
I'cnant Namc: UNITI.:D MI"DICA1.GROUP ""CRI=:Di1'S*'' SWR� NIA
Sirc.\ddress: 9973 SW f'RUWING S1'SUITE 220 PI.:\I= 2015-00397
Parccl #: 2S 102CB03200
l.'i.Xttire Value Pre\-ILIUS Previous Credits Capped fixture I"iXrure Nev, New
yah:c count V aloe count added r added value total#s total valucS
Ba tiscry/f"onr 4 0 0 0 0 0
Bath: -Tub/Shrnvcr 4 0 0 0 0 0
-jacuzai/WlIirl Tool 4 0 0 0 0 0
Car\\-ash: - C•:ach Stall 6 1 0 0 1 0 0 0
Drive through 16 0 0 0 0 0
Cus Iidor/Watet'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
I\e\\ash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 0 0 0
3 inch 5 0 1 0 0 0 0
4 inch 6 0 0 0 0 0
Car Wash 6 0 0 0 0 0
(larbagc Disposal:
- Domestic(to 3/4 IIP) 16 0 0 0 0 0
-'Commercial (to 5 1-II') 32 0 0 0 0 0
- IndllSrilal (over 5 1-1 P) 42 0 0 0 0 0
Ice AIachux•/Refrigerator Drain 1 0 0 0 0 0
l.ivin" Unit 16 0 0 0 0 0
Oil Sell(Gas Station) 6 0 0 0 0 0
RCC. \'chicle DUMP station 16 0 0 0 0 0
Showcr: -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 5 10 5 10
-Bradlcv 5 0 0 0 0 0
Com/Scry/Uril - 1-4,od Rclarcd 3 0 0 0 0 0
Swimming Pool filter 1 0 0 0 0 0
\Vashcr-Clothes 6 0 0 0 0 0
Water 1_snactor 6 0 0 0 0 0
Water Clnscr-Toiler 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous FDU CoUnr 0 0
Gapped FDU Credit 1.2 19.2
0 0 0 0 1 5 1 10 5 -9.2
i.urrcm Pisturc\attic -9.2 divided b 16= Q573 Current FDU 1 EDU= $5,100.00
PrCVioUS l�isture A'aloe 0 divided by 16= 0.000 PCCCIUUS 1.
Charntie -9.2 drvided be 16= -0.373 over (under) S (2,958.00)
Enter EDU Change Here -0.530
"Round L'DUs to the nearest 1/100th: a Q)Unr ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Neta.:=CRI Di"PS""Credits from PI—M2012-00025 applied to this permit.
Authorized Name/Signature: Debbie Adamski Date: 12/7/2015
Building Division
[Note: The property owner shall retain the ORIGIN.A],scxcr talk record. if credits exist,this document will serve as a voucher Which must be
submitted to the City of'l'igard Building Division to redeem credits towards future System dcyclopment char',
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