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Permit (101) IIECE. IVO) City of Tigard ° COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action SEP 9 Z01.5 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www. � . c � nrArr. Ali TO: CITY OF TIGARD Building Division I 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov`6// $_ FROM: 71 Owner ❑ Applicant ❑ Contractor ❑ City Staff Check(/)one REFUND OR Name: `-(C INVOICE TO: (Business or Individual) (4 1 (Z 1Lc �J/1-k Mailing Address: gl174 S I 4L 2 ST, / ft City/State/Zip: T/'&- Ró , Gt72 z4 Phone No.: 4 2r 6119 2 70.S' PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): al CANCEL VOID PERMIT APPLICATION. t F NSUJ E' NIT FEES (attach copy of original receipt and provide explanation below). ,aIM/ INVOICE `0 " FEES DUE (attach case fee schedule and provide explanation below). OVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: T o'('/6" 63.0 Site Address or Parcel#: 95q/ 'Sr Project Name: 2 PI 1,3 Subdivision Name: Lot#: EXPLANATION:. NX/& V J( L t.- P 0 I/E /g C I��5 A/ (1L �. Signature: � � Date: 0 q/0q 2 d ir Print Name: tM t ' Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fcc 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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: Date '70,113.11171AM Route to Records: Date 49 /AMII B Refund Processed: Date N C i All Invoice Processed: Date By Permit Canceled: Date /44h5 By -,,�ri Parcel Tag Added: Date By I:\Building\li orms\RegPermitAction_092314.doc City of Tigard • COMMUNITY DEVELOPMENT Building Division 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TIGARD INVOICE TO: Mircea Ban Customer ID: C15-0003 9541 SW Inez St Invoice No.: INV2015-00006 Tigard, OR 97224 Invoice Date: 10/1/2015 Date Due: 11/1/2015 ;-Case No Site Address - „ • Subdtvision Lot#or.Project.Name Amount Due. MST2015-00143 9541 SW Inez St Balance of plan review fees due $88.00 for plan review completed prior to request for peuttit cancellation Invoice Total: $88.00 ® Please see attached fee schedule for description of fees due. (Detach and return this portion with payment.) Case No.: MST2015-00143 Customer ID: C15-0003 Site Address: 9541 SW Inez St Invoice No.: INV2015-00006 Project: Ban Invoice Date: 10/1/2015 Date Due: 11/1/2015 Invoice Total: $88.00 Amount Paid: $ Office Note: Route copy of receipt to Dianna Howse Please mail payment to: City of Tigard, Building Division Attn: Dianna Howse 13125 SW Hall Blvd. Tigard, OR 97223 1:\Buil ding\Accounting\Invoice.doc 01/14/2011 I1 CITY OF TIGARD FEE AND PAYMENT HISTORY 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIIQ RD' MST2015-00143 - 9541 SW INEZ ST, TIGARD, OR 97224 Revenue Payment Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due Plan Review 230-0000-43106 $718.87 $718.87 $718.87 8/6/15 Credit Card 202020 $0.00 DC Provision Review, SF-Ping 100-0000-43112 $88.00 $88.00 $88.00 Totals for Fees $806.87 $806.87 $718.87 $88 Receipt# Payment Method Check# Payor: Receipt Date Receipt Amount 202020 Credit Card Mircea Ban 08/06/2015 $718.87 Total Payments: $718.87 Balance Due: $88.00 ,, =clding Permit Application V 41 I /0 8' 4ry Residential RECENED FOR OFFICE USE ONLY. • '` City of Tigard Date/Bed_ a A Permit No.: � /6_-- ,/ 13125 SW Hall Blvd.,Tigard,OR 97223 U' 6 2Q15 Plan Revie l r ■ a-° Phone: 503.718.2439 Fax: '503.598.1960 Date/B : ��{�+ gs' Other Permit�,_ ,/i..._40, 5-00/60 Inspection Line: 503.639.4175 z Date Read luris: El See Page 2 for l'IGARI�; IL� � Notified/Method: Supplemental-Information L. .:- - e � Internet: www.tigard-or.gov C''� �� `. 9 .f,9 '•i - BU9LDR `�G i-;i ISION ^, „. TYPE OF WORK . ' „.;.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. • • 1-and 2-family dwelling ❑Commercial/industrial Valuation: $ 4,.. - ` Number of bedrooms: ❑Accessory building ❑Multi-family . ❑Master builder ❑Other: Number of bathrooms: aC , S . JOB SITE`INFORMATION AND LOCATION • . Total number of floor' Job site address: CI Sef/ ' ,a J ` �Sr New dwelling area: .3e square feet • City/State/ZIP: -7-7 (fj,1i0 ®� Garage/carport area: a square feet _ Suite/bldg./apt.no.: Project name: ' yI KD Covered porch gaze square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet REQUIRED DATA:COMMERCIAL-USE.CHECKLIST Subdivision: I Lot no.: Permit fees*are based on the value of the work performed. �6, it( F2� (/^kg co Indicate the value(rounded to the nearest dollar)of all Tax map/parcel no.: equipment,materials,labor,overhe ad,an d the profit for the ~' -,' DESCRIPTION OF WORK work indicated on this application. [ill ti . cx,p'ra, 649/1°C2 / 77�6 M��� mac, ` Valuation: $ Z.--/ A./6 I ! A'/'�/r c/G 7� Existing building area: square feet G,f p& j,C2g&71 A7V1A-) MT,// /A/FA/S/7 P!..g > New building area: square feet ® 'PROPERTY OWNER - - ,❑ TENANT - Number of stories: • Name: 11/4.1'l/C A-- J Type of construction: . N. Address: q5--W 9 Gt! bv&fr Occupancy groups: • ■ _ %7 fi, -/) N City/State/ZIP: Existing: Phone: �i p "'67�era-Z 70 5- Fax:( ) New: [APPLICANT . ':0 CONTACT PERSON ,• - .BUILDING PERMIT FEES* 4 f--"Z.- a C•_ ,�� n w IC? •' YPledse.refer to fee schedule) - . . Business name: � �jylJ ,v 7 Structural plan review fee(or deposit): N. Contact name: !.�C'(> — ��9 ' f ,MAW Q ,f��07155-A) FLS plan review fee(if applicable): Address: �� pV 4 City/State/ZIP: 9il-�9 97 e3 z Total fees due upon application: ee��gg,, ,�+ �pp Amount received: 471g,Phone:( ic�� �! Fax::(.- (iv�'E-mail: 2 Zi/V Z�P iI /0 2 p' CAS W PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*L.•(� Commercial and residential prescriptive installation of , CONTRACTOR C1s;,a roof-top moon d Photovoltaic Solar Panel Sy m. �' Business name: /�1-e) A ) E� Submit two(2)se of roof plan with co • ion details v I` and fire department a ess,along '. the 2010 Oregon Address:• Solar Installation Specia Co. checklist. ' City/State/ZIP: Permit Fee(include . •.. review $180.00 ` `\ and a• istrative -es): W Phone:( ) Fax:( ) State surchar•. 12%of permit fee . - $21.60 CCB lie.: Tot.. fee-dui upon application: - - $201.60A;. Authorized signature:' „if,'" / This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: (c) Date: N/J *Fee methodology set by Tri-County Building Industry Service Board. L:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 4404613T(I I/02/COM/WEB) 1 PhCity of Tigard q COMMUNITY DEVELOPMENT DEPARTMENT T l G AR>D' Building Permit Review — Residential i ran. �....�,_,>-+�.cera�- sa, -•.E.�. �xc�zm:.scr-.0 v--=u,yo-:�...c-�s _=.tea _ arw.m. ,._..;.:r>irw Building Permit #: 1'463TraO tS-OU /43 Site Address: 9,TO 4'/ 7./e Project Name: iga,ri 4f// C, ,4 Lot #: (New dwelling= subdivision name;Addition or Alteration=last name of owner) Planning Rev,Y l w Proposal: / ,dd l 1a5 if37 COv/Y l;av eCS/t-, )41 S / r. ke)Pr/ GAS ea'1 / pv.S _r /phc1N . ,,, ViD✓' S ./,»4,A. fly XVerify site address/ ite# exists and active in permit s'ste . ❑ River Terrace Neighborhood: ❑ Yes No Site Plan Elements: bree (3) copies of site plan Ja fisting structures on site fire plan must be on 8-1/2"x 11"or 11 17"paper Footprint of new structure(including decks)with finished Drawn to scale(standard architect or engineer scale) floor elevations Torth arrow - ❑lftility locations (required for new,may apply for additions) Site address,project or subdivision name and lot number 'etocation of wells/septic systems • plicant information (name and phone number) ❑Erosion control (including drainage-way protection, silt fence 'I MI of dimensions and building setback dimensions design,location of catch basin,etc.) t lot area,building coverage area,percentage of coverage and Street names impervious area (applicable if R-7,R-12,R-25&R-40) ❑Street tree size,type and location - ❑P'roperty corner elevations (2 foot contour lines if more than ❑Existing trees to be retained with drip line,and tree 4 foot differential) protection measures ❑ Clean Water Services—Service Provider L t to,(lot platted prior to 9/10/1995): Required: ❑ Yes,applicant was notified No Received: ❑ Yes ❑ No ❑ Public Facilities Improvement(PFI) Permit: Required: ❑ Yes,applicant was notified > No Applied For: ❑ Yes ❑ No, stop intake ❑ Land Use Case #: big- ❑ Zoning: /- 4( ❑ Setbacks: Front "1J Rear /5— Side CJ Street Side _ Garage ,20 ❑ Landscape Requirement: • ❑ Lot Coverage Maximum: % ❑ Building Height: Maximum Height /14 C4.- Actual Height ❑ Visual Clearance ❑ Easements ❑ Sensitive Lands: ❑ Yes ❑ No Type ❑ Urban Forestry Plan ❑ Conditions "Met"prior to issuance of building permit/040005 Notes: Aa l ts►vti, OP" D eS4e1"- d'fr ct tufra Approved By Planning: Date: '-e Revisions (after Building Sub at only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: ❑ Approved ❑ Not Approved I:\Buil ding\Fonns\BldgPennitRvw_RES_070915.docx ■ ♦ , Building Permit Submittal Original Submittal Date: ee /5.-- Site Plans: # Building Plans: # 1 Building Permit#: []'Enter building permit#abo e Workflow Routing: ,2'Planning O'Engineering R' Permit Coordinator C-)wilding Workflow Sign-off: 21" Sign-off for Planning(include notes from planning review) Route Application Documents: Er Engineering: (1) copy of permit application, (1) site plan, (1) building plan and original plan review routing form. Building: original permit application, site plans, building plans, engineer and beam calculations and trust details,if applicable, etc. Notes: _ , _i ./ ,�.� , : ,4 i ' ' `• - i • 'O - bp(c)6744-- By Permit'1'e rnnician: i Date: it En ineering Review af Slope at building pad: ❑ Conditions "Met"prior to issuance of building permit ❑ Easements (encroachments)per engineering conditions of approval and plat • ❑ Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes -No Assess Water Quantity Fee in-lieu: ❑ Yes No LIDA Facility on lot: ❑ Yes iCJ 1l 0 ❑ NOT Approved by Engineering: Date: Notes: Approved by Engineering: lilt(kkrt. _ kJ, Date: � ./ Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: ❑ Approved ❑ Not Approved Permit Coordinator Review ❑ Conditions "Met"prior to issuance of building permit I ❑ Approved, NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: • . Revision Notice 3: Date Sent to Applicant: ❑ SDC Fees Entered: Wash Co Trans Dev Tax: ❑ Yes ❑ N/A Tigard Trans SDC: ❑ Yes ❑ N/A Parks SDC: ❑ Yes ❑ N/A OK to Issue Permit Approved by Permit Coordinator: / Date: 2/Z6 5- I:\Building\Fonns\BldgPennitRvw_RES_0709I 5.docx Ric ; p:Vf•/ >• ��' AUG 2015 • PROP. • 60.000 , D9 -,., LINE c4u!L���= ;;;_ • 82.000/ NOTES: EXISTING 4' DIA SEWER CONN. EXISTTNG CITY WATER • / EXISTING GAS LINE ♦ ...11k \ ' 34.773 LAWN 410- \ PROP. • LINE it Ak \ ' ' '''. 36.682 it ®v /24.644 S' ' # /2.655 ∎•� .mac, n'J!n /5.141 �i�i�.�,►1,1,,,,,,,.... Ir tt Vii Ira� .= zi.:+ VI LAWN e f REMODELING I }l',!-„., • e LAWN AREA ��.:.'r6.. I. tve( i; '0, —''' I� 125.950 � e•v,10*---...- -,4'4 .: 5.1.1 114.140 \ �;C•=;r a,�j I'����4`7.j --- r 44t► .♦'�� • I i���•� :►�it.� �I;�L 1"/12' SLOPED e ;►�,� •:�,y:���9 ,� RAMP I A �\ \ �;ri■ LAWN \ \ V 0 1 0 e ` \ • CITY OF TIGARD — a �r� r •Approved b Planning 38.'98 �6//S by g 37.464 EXISTING / -/ \ CDNCRTE • Date: , � s it DRIVEWAY . Initials: : e gilt S1D 11*K PROPERTY AGGRESS:9541 SW INEZ ST. TIGARD, DR.97224 MAP/TAX LOT: 251118A06800 . ACC.#: 81471133 P 9541 SW INEZ ST. iii OA SITE PLAN' SCALE: l'. 20'-0' III - Accumulative Sewer Tally 'Tenant Name:Ban Mircea SWR# 2015-00100 41 Site Address: 9541 SW Inc,St Fl.iM # MS1'2015-00143 Parcel#: 2S111BA06800 Fixture Value 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 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 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 Eve Wash 1 0 0 0 0 0 Floor Drain/Sink: -2 inch 2 0 0 0 0 0 -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 1-1P) 16 0 0 0 0 0 -Commercial (to 5 HP) 32 0 0 0 0 0 -Industrial (over 5 I-IP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 Living Unit 16 0 0 2 32 2 32 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: -1-.av/Bar-Non-Food Related 2 0 0 0 0 0 -Bradley 5 0 0 0 0 0 -Com/Sere/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 1 16 0 0 16 Capped EDU Credit 0 •I'O'lAI,S _ 0 _ 16 0 0 2 32 2 48 Current Fixture Value 48 divided by 16= 3.000 Current EDU 1 EDU= $5,100.00 Previous Fixture Value 16 divided by 16= 1.000 Previous EDU Change 32 divided by 16= 2.000 over (under) S 10,200.00 Enter EDU Change Here 2.000 '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: Due to the number of bedrooms&water meter size(<3/4")sewer to be calculated at Residential II Rate(1 DU/1st 5 bdrm + 1 DU/ca add'l 2 bdrm) 10 bedrooms=1 13DU for 1st 5 bedrooms,2 EDU's for the additional 5 bedrooms=3 EDU's-'I EDU already existing=2 additional EDU's to be charged. Authorized Name/Signature: Debbie Adamski Date: 8/6/2015 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. I:A Building\Sewer Tally\SewerTal1vSheet_511-111_07111 15.xlsx r rt Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325 (2)) This statement is required for residential building, electrical, mechanical,and plumbing per mits. Licensed architect and engineer applicants,exempt from licensing under ORS 701.010(7), need not submit this statement.This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that a II subcontractors who work on the structure must be licensed with the Construction Contractors Board. � r & will be performing work on property I own, a residence that I reside in, or a residence that I w ill reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. 9t CC rint Name o Permit Applicant QS P6(20/c Signature f ermitApplicant Date Permit#: H 1 -.001 `t Address: 9541 I dcJ f�Z I i5rti v 2 g 7 X77 4/Z • Issued by: Date: f=1 This Copy for Permit Offices IIin CITY OF TIGARD MASTER PERMIT B . COMMUNITY DEVELOPMENT Permit MST2015-00143 T IG ARU 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/28/2016 Parcel: 25111 BA06800 Jurisdiction: Tigard Site address: 9541 SW INEZ ST Subdivision: BUTLER TERRACE Lot: 2 Project: Ban Project Description: Convert existing garage into habitable space for foster care. Some interior remodeling. Trade work under separate permits. BUILDING Floor Areas Required Setbacks Required Stories: 2 Bedrooms: 6 First: 638 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 7 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Yes Total: 638 sf Value: $100,000.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 Drains: 0 Tubs'Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add!500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ADD SF VB R-3 638 Owner: Contractor: BAN,MIRCEA&DIANA OWNER Required Items and Reports(Conditions) 9541 SW INEZ ST MIRCEA BAN TIGARD,OR 97224 9541 SW INEZ ST TIGARD.OR 97223 PHONE. 425-919-2705 PHONE: 425-919-2705 FAX: Total Fees: $3,016.99 This perm ' 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 •.ne in acco •.nce 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 d. s. ATTENTION: ► egon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR •52-001-0010 through OA' 9 -I i 0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800. 2.2344. XHued By: /0 / ��.. 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. RECEIVFp xEsttg „—� is/2/is -/VO (gjiddin2 Permit Appl><ca ion Residential UC 12 1 2015 _ ,� � rc�ii clrl icer �i c►\i 11 • TIGAR� Received City 4 11- I t DateB : . / _ i Permit No.: -/--- 6/6-----Lor i ld lig _ 11 13125 a 1 ' - ib"w I AUG 6 1 Plan Revie Wa p& h ■ Phone: 503.718.2439 Fax: 503.598.19K0 Date/By. i , , 1. ( Other Permit' , /i 5 lex Inspection Line: 503.639.4175 �+ ; Date R .. :,: , Irl .roils: ® See Pige 2 for . I I c t:t r '.' 3 -'` 3 Notified/Method: /6 ' i� 412/A, Supplemental-Information Internet: www.tigard-or.gov S U 1 ., I I u S;r fi a W , slJk J ss��jj�t i r ,Q � ` - aur r• z . � 0 New construction 0 Demolition Permit fees'are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all yi-Addition/alteration/replacement 0 Other equipment,materials,labor,overhead,and the profit for the a, ',.i.,-!., work indicated on this application. at d 2-family dwelling 0 Commercial/industrial M1 Valuation: S jaa - "'t ❑Accessory building 0 Multi-family Number of bedrooms: 3 n ❑ Number of bathrooms:Master builder 0Other: ' `-) • t, C 1'1,-"'"0.10,4100/4",.'"444' , _ Total number of floor Job site address: C7 / ' 1 I J New dwelling area: square feet City/State/ZIP: T.1Garage/carport area: Nig square feet Suite/bldg./apt.no.: Project name: 0 Covered porch ar lea{ square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet Subdivision: Lot no.: Permit fees'are based on the value of the work performed. Indicate the to Tax map/parcel no.: .2 it i 6. 0 i'g 0o equipment,m terials,abor,overhead,and the profit for the _ C� �. . - -+ I t , E ,. t ,jt :' ' :reit work indicated on this application. C .,, 47(/ l/uC7 Pry/ TM)67 ' '- / /O r Valuation: $ Existing building area: square feet C-471-.V / `7c / / V/#U 14' f/1L/k ,(./%r /� New building area: feet square rte.... '�-•` _� �- . .- Number of stories: Name: H1/2 C�4--- ) Type of construction: - -,` - Address: q 5'/ S Cl) /N& -- Occupancy groups: City/State/ZIP: 77 e>/t74 C✓ Existing: Phone:4Z 5 —6#.1,— %f Z 70 5 Fax ( ) �ANew: a " 'f..yy ,.,f � �r {`m +P ON ,� fit. 4..f,!--k, n° J E!fs�i .'41 f :�M J 'y . ,. �: .t � ;,., t ;'". � � � ' is a.r � s 'f Business name: Structural plan review fee(or deposit): cay..),..._ ,„,.,„.. Contact name: ` E ,t__.__s,rL-L' 6f j9 ,, � /1,64 iinC «S A 1 FLS plan review fee(if applicable): Address: ��k f /v I__ 4 lam! ti� ^ – 97 , Total fees due upon application: City/State/ZIP: ('JJ Amount received 417 r 8', � C Phone:( A -A6/ f Fax::(` 24, ' G 2_ 7 E-mail: / ei&i- --c 7V/Y l �J� /- C7 ✓ ":" , ,-,, i 1• ,!. ' ''''''\''' l"[ll ) , ';tom `s: Commercial and residential prescriptive installation of .l Citi `,,� ; roof-top moa .-d Photovoltaic Solar Panel Sys i Business name: O C.F) Submit two(2)se of roof plan with co.• ion details and fire department a ss,along '- the 2010 Oregon Address: Solar Installation Specia C.. checklist. - City/State/ZIP: Permit Fee(include . :,.review $180.00 k and a• ^ istrative -es): Phone:( ) Fax:( ) State surchar:: 2%of permit fee . $21.60 CCB lic.: Tot., - -due upon application: - $201.60-\ Authorized signature:),/ This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name: ��te/ l/}f Date: t/9, -,//li "Fee methodology set by Tri-County Building Industry (/rService Board. I:\Building\Peimits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) i. PhCity of Tigard w COMMUNITY DEVELOPMENT DEPARTMENT T 1 c n 1;D Building Permit Review — Residential Building Permit #: 1--- '3TC} (5 -C c /43 Site Address: 9517/ 27/1e - Project Name: 6, lf/ ci-A— Lot #: (New dwelling= subdivision name;Addition or Alteration=last name of owner) Planning Rev,] I y� L ,. �C I. Proposal: /V(lt!/` - o of�fi/ awe CCv� E✓Sf 4- .5 / i�+'6 6dS tea,veI V/ ip/✓.) J t _ I� i vele-14,c_ it 1 d-t -A- Os.fr %Verify site address/S'uite# exists and active iiin�'pe�Armit s rste . /y ❑ River Terrace Neighborhood: ❑ Yes No Site Plan Elements: ree(3)copies of site plan , lxisting structures on site itplan must be on 8-1/2"x 11"or 11 x 17"paper Footprint of new structure(including decks)with finished Drawn to scale(standard architect or engineer scale) floor elevations 4orth arrow Utility locations(required for new,may apply for additions) ite address,project or subdivision name and lot number ''$llocation of wells/septic systems .plicant information (name and phone number) ❑Erosion control (including drainage-way protection,silt fence 01 ot dimensions and building setback dimensions design,location of catch basin,etc.) 1slLot area,building coverage area,percentage of coverage and ❑Street names impervious area (applicable if R-7,R-12,R-25&R-40) ❑Street tree size,type and location Bhroperty corner elevations (2 foot contour lines if more than ❑Existing trees to be retained with drip line,and tree 4 foot differential) protection measures ❑ Clean Water Services—Service Provider L tter ot platted prior to 9/10/1995): Required: ❑ Yes,applicant was notified No Received: ❑ Yes ❑ No ❑ Public Facilities Improvement (PFI) Permit: Required: ❑ Yes,applicant was notifiedNo Applied For: ❑ Yes ❑ No,stop intake ❑ Land Use Case #: /V>/- ❑ Zoning: /- `7'j ❑ Setbacks: Front "l.J Rear /5— Side c Street Side Garage 0 ❑ Landscape Requirement: ❑ Lot Coverage Maximum: °/o ❑ Building Height: Maximum Height /14-C4)t-, Actual Height ❑ Visual Clearance ❑ Easements ❑ Sensitive Lands: ❑ Yes ❑ No Type ❑ Urban Forestry Plan ❑ Conditions "Met"prior to issuance of��building permiecv47•j / Notes: /AM PMa•t, 0 es62GPL" dp4,6 t a rill Approved By Planning: ���� Date: f��/ -- Revisions (after BuildingSub Olic.l only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: ❑ Approved ❑ Not Approved i:\BuildingTomis\BldgPermitRvw_RES_070915.docx 1 11/4, Building Permit Submittal Original Submittal Date: a 0 / Site Plans: # Building Plans: # `3 BuildingPermit #: ErEnter building permit#above. Workflow Routing: 2 Planning a"—Engineering 2-Permit Coordinator R.—1371ding Workflow Sign-off: B' Sign-off for Planning(include notes from planning review) Route Application Documents: ef Engineering: (1) copy of permit application, (1) site plan, (1) building plan and original plan review routing form. (Building: original permit application, site plans,building plans, engineer and beam calculations and trust details,if applicable, etc. Notes: _ 1 i _ii tea_:_ ,410 aJ ✓V.Lece `. ' . -To - 41' 1bac1f_1J2c-,� By Permit Te'lnician: � ____)c c Date: e" .1 En neering Review Slope at building pad: ❑ Conditions "Met"prior to issuance of building permit ❑ Easements (encroachments)per engineering conditions of approval and plat ❑ Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes ,eNo Assess Water Quantity Fee in-lieu: ❑ Yes No LIDA Facility on lot: ❑ Yes ..-E1—No ❑ NOT Approved by Engineering: Date: Notes: Approved by Engineering: 141.(kGlt_— 142, Date: l" Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: ❑ Approved ❑ Not Approved Permit Coordinator Review ❑ Conditions "Met"prior to issuance of building permit i ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: Revision Notice 3: Date Sent to Applicant: El SDC Fccs Entered: Wash Co Trans Dev Tax: ❑ Yes ❑ N/A Tigard Trans SDC: ❑ Yes ❑ N/A Parks SDC: ❑ Yes ❑ N/A (fAVOK to Issue Permit Approved by Permit Coordinator: 41/ Date: -/6 s- 1:\Building\For ns\BldgPennitRvw_RES_070915.docx • Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.325(2)) This statement is required for residential building, electrical,mechanical,and plumbing per mits. Licensed architect and engineer applicants,exempt from licensing under ORS 701.010(7), need not submit this statement.This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that a II subcontractors who work on the structure must be licensed with the Construction Contractors Board. r • will be performing work on property I own, a residence that I reside in, or a residence that I w ill reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. 'Print Name o Permit Applicant .111111 A itirie 08/Q0 (201r Signature •f •ermitApplicant Date 9 Permit#: a -0614 Address: 9.50 tJ /1`)i 4004 �C �2�, v2 c, 7�2,� � �., • '�i r Issueti=br-2 48" ' • •• !.t.Y This Copy for Permit Offices sII Accumulative Sewer Tally i al Tenant Name: Ban Mircea SWR# 2015-00100 Site.Address: 9541 SW Inez St PLM# MST2015-00143 II( ARI) Parcel#: 2S 111 BA06800 Fixture Value 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: -'l'ub/Shower 4 0 0 0 0 0 - jacuzzi/Whirlpool 4 0 0 0 0 0 Car Wash: -Mach 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 0 0 0 -Domestic 2 0 0 0 0 0 Drinking Fountain 1 0 0 0 0 0 I?ve Wash 1 0 0 0 0 0 Floor Drain/Sink: -2 inch 2 0 0 0 0 0 -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 I IP) 16 0 0 0 0 0 -Commercial(to 5 I IP) 32 0 0 0 0 0 -Industrial(over 5 IIP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 Living Unit 16 0 0 2 32 2 32 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 0 0 0 -Bradley 5 0 0 0 0 0 -Com/Serv/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 I?xtractor 6 0 0 0 0 0 Water Closet-Toilet 6 0 0 0 0 0 Urinal 6 0 0 0 0 0 Previous I?DU Count 1 16 0 0 16 Capped I?DU Credit 0 '1'(YI':1LS 0 16 0 0 2 32 2 48 Current Fixture Value 48 divided by 16= 3.000 Current!MU 1 EDU= $5,100.00 Previous Fixture Value 16 divided by 16= 1.000_ Previous 1?DU Change 32 divided by 16= 2.000 over (under) S 10,200.00 Enter EDU Change Here 2.000 *Round l IDUs 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: Due to the number of bedrooms&water meter size(<3/4")sewer to be calculated at Residential II Rate(1 DU/lst 5 bdrm+ 1 DU/ca add'I 2 bdrm) 10 bedrooms=l I?DU for 1st 5 bedrooms,2 EDU's for the additional 5 bedrooms=3 11DU's- 1 IIDU already existing=2 additional I.DU's to be charged. Authorized Name/Signature: Debbie Adamski Date: 8/6/2015 Building Division Note: The property owner shall retain the ORIGIN:],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\Sewer'fallyShect_51111)_I171)115.xlsx Ar Rit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT11111 a� Request for Permit Action EP 9 2n15 is 1 , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ifet4T1/I,.- . v;1v 91Arr ""b .1"I viC101i TO: CITY OF TIGARD t BuildingDivision ! 13125 SW Hall Blvd.,Tigard,OR 97223 u Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov4� $' FROM: Owner 111 Applicant El Contractor 111 City Staff "" Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Jk/)( j Z 1L'.yg" 31� Mailing Address: `J i lli S W I)e 2 S T / 1C e City/State/Zip: '/ / G-L-4 Ró 0 , q72 24 Phone No.: 42 S 9'/9 2 / o,- PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 12 CANCEL VOID PERMIT APPLICATION. • ' _ _ . I PE' IT FEES (attach copy of original receipt and provide explanation below). ,e_210 INVOICE `! ' FEES DUE (attach case fee schedule and provide explanation below). a. • 'OVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: H‘D7— D O/ ' CO / 2D Site Address or Parcel#: 95-q/ Lk-' /1,i f7__ er Project Name: �JP1 lJ Subdivision Name: Lot#: w EXPLANATION:. NV E V("( L.t.- (/ 1 O E g X-CIC /(. Vi'd S /;q /e3 1 / LT--.4 77-E- t r Signature: - Date: Q q/0g 2 C)fS Print Name: r • CLQ- FA ii- Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: _ Date 9 9 /5 :y T Route to Records: Date ( / /,$ By /i... Refund Processed: Date N 4 i' IA Invoice Processed: Date By Permit Canceled: Date AV/1/3" By ,_ t _ 'arcel Tag Added: Date By \ I:\Building Forms\RegPermitAction_09t3-f4.doc City of Tigard • COMMUNITY DEVELOPMENT 111 Building Division TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov INVOICE TO: Mircea Ban Customer ID: C15-0003 9541 SW Inez St Invoice No.: INV2015-00006 Tigard, OR 97224 Invoice Date: 10/1/2015 Date Due: 11/1/2015 Case No. Site Address Subdivision-Lot#or Project Name Amount Due MST2015-00143 9541 SW Inez St Balance of plan review fees due $88.00 for plan review completed prior to request for permit cancellation Invoice Total: $88.00 ® Please see attached fee schedule for description of fees due. (Detach and return this portion with payment) Case No.: MST2015-00143 Customer ID: C15-0003 Site Address: 9541 SW Inez St Invoice No.: INV2015-00006 Project: Ban Invoice Date: 10/1/2015 Date Due: 11/1/2015 Invoice Total: $88.00 Amount Paid: $ Office Note: Route copy of receipt to Dianna Howse Please mail payment to: City of Tigard,Building Division Attn: Dianna Howse 13125 SW Hall Blvd. Tigard, OR 97223 I:\Building\Accounting\Invoice.doc 01/14/2011 CITY OF TIGARD FEE AND PAYMENT HISTORY - 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD MST2015-00143 - 9541 SW INEZ ST, TIGARD, OR 97224 Revenue Payment Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due Plan Review 230-0000-43106 $718.87 $718.87 $718.87 8/6/15 Credit Card 202020 $0.00 --- DC Provision Review, SF-Ping 100-0000-43112 $88.00 $88.00 $88.00 Totals for Fees $806.87 $806.87 $718.87 $88 Receipt# Payment Method Check# Payor: Receipt Date Receipt Amount 202020 Credit Card Mircea Ban 08/06/2015 $718.87 Total Payments: $718.87 Balance Due: $88.00 lding Permit Application 's •. /0 1 8' .4# Residential RECEIVED 101201 I I( I 1 til O\I 1 City of Tigard Date/B ._ ed /i c ,'T-Pe)/5"---700% /� Permit No.: ,� 4 13125 SW Hall Blvd.,Tigard,OR 97223A, G 6 2 Q 15 Plan R e a C (�pther Permit 5 /ilk Phone: 503.718.2439 Fax: 503.598.196 Date/By: g , , i,, ,,;l Inspection Line: 503.639.4175 CI —r_ o-;^q,, Date Read' kris ® See Page t for w Internet: ww .tigard-or.gov l q•y Notified/Method: Supplemental-Iaformadon - 8r,,4s� i��; 4,a"•,ay/ N ' 1, ir '' . ,.�" ,�::: -,,i,,,,,,,,,;'..rn..,k 4;,lM4•.„:,-4£'P � :f, a '?u , ,"t4, , ,,.. ,,,,,,`Y'i,".uSr_I ., '+:, ❑New construction 0 Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all yik-Addttton/alteratton/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the r - ..' 'c'^ € work indicated on this application. '`O4„ to i' ^ $ of +s t .m., 4. , -and 2-family dwellingValuation: $ - -� 0 Commercial/industrial 0 Accessory building ❑Multi-family Number of bedrooms: 3 r 0 Master builder 0 Other: Number of bathrooms: !2 , 7 mh m ', a t o s i,E Y ' A ' ... Total number of floor— Job oor Job site address: CI f/ � ! 1/ 9A-- New dwelling area: square feet City/State/ZIP: T7 A-77,0 ®/L Garage/carport area: Acit square feet Suite/bidgiapt.no.: Project name: ...--1709- 0 ! j.3 Covered porch arias square feet Cross street/directions to job site: Deck area: square feet Other structure area: square feet ity aft m x '";"4A.,.'” _.. - Subdivision: Lot no.: Permit fees*are based on the value of the work performed. / no.: �� ��� fLj. �( Indicate the value(rounded to the nearest dollar)of all , Tax map/parcel p p equipment,materials,labor,overhead,and the profit for the ,, ,4,ito • �` - ,• '� i work indicated on this application. C V 1(/6'l/UC7 Pt/'E,T/4)6 / /0 Valuation: $ /7V/# MT// i � _ Existing building area: square feet Cl77'W f ��/a 6 ��/ONI /4-- For--,7t---7z- � i lk/R, ./Si,_ 4,„!v _ New building area: square feet C .,., .I' 4• . ,4e, r 2;`„ t i :"•,. *rk Number of stories: Name: //2`j U--- 7 J Type of construction: Address: q 6-I,/ S C4) /AJ&G Occupancy groups: City/State/ZIP: 77e) Existing: Phone 4ZS ^6,/% Z 70 5" Fax ( ) New: 2, Business name: /Z 1 —9/6vv C vCv� nN ral plan Structural plan review fee(or deposit): Contact name: 7 ,g47a 4:S C.(1 dr/f__ /qb , Q 7?c ir/55A) FLS plan review fee(if applicable): Address: oi/i ty �p97 ,ZTotal fees due upon application: City/State/ZIP: Z L ! F� 47!g, g•7 � Amount received: Phone:( �' 7 I Fax::( �' 0/7%,Z E-mail: 71Z-/4tl&/-- a O'ir CtSr; r: t ,;",, -_> /';;„.. .",,,,„1,,,A,,,,,-L.-.,- i Commercial and residential prescriptive instal on of ''t „ �' t _ ~i •. �," r 4roof-top mo . -d PhotoVoltaic Solar Panel S -,a... Business name: Q -1) J(v e- Submit two(2)se.. of roof plan with col• 'r on details and fire department a• :ss,along •: the 2010 Oregon Address: Solar Installation Specia C.• checklist. Permit Fee(incl •- . :•• review City/State/ZIP: $180.00 k and•• , strative ): Phone:( ) Fax:( ) State surchar:•• 12%of permit fee . $21.60 CCB lic.: To : e upon application: $201.64.. Authorized signature:" /(--- , This permit application expires if a permit is not obtained ��/ within 180 days after it has been accepted as complete. Print name: j C/7 - �l6) Date: byf '//J *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB) a ♦/ . C...•,.., :. AUG 6 20/5 /' LPROP • 60.000 C4j�alt: INE 1,t'/4, • 82.000/♦ ♦ • "' MOTES: EXISTING 4' DIA SEWER CONN. • EXISITNG CITY WATER • EXISTING GAS LINE ♦• IN .1 / \ 34.773 LAWN A—PROP. ♦ LINE \), _ it 36.682 • d• 24.644gill. / • • 11 • • • \.... 12.655 ••4•0&" 1����►� C•..� & � mly,"1 � u 15.141 ►���t ? it 10 A�..-, s VI ait.� „ e7Ls LaWN�"Vr � X , 7. • • ,REM:CELIAC ' �--. • • LAWN AREA •-•` �� , � a4 0 .4, 4, L ► / V I r. V• '.t :cij,go:.:♦:., ; 126.950 •�1��li'��rr 1.4 `ll 5.1•, 114.140 ` �,(W'Cia ��\��jb��#j�'.j • • ,�.1.#. At4 . P/12"aSL PEO r,�i► 1,0.i►�. i� / �\ i • IV A i A\ \ LAWN \ , \ • \tt./ ni I Fa) , .,.„,„ t -..../ CITY OF TIGARD �,, W' • Approved byPlanning \- 38.•98 76 /5 1139,1 PP 37.464 EXISTING / /-/' ` CONCRTE • Date: b 5 • DRIVEWAY • Initials: • A, Ii *K PROPERTY ADDRESS:9541 SW INEZ ST. TIGARO, C P.97224 MAP/TAX LOT: 2S1118A06800 ACC.N: R1471133 P 9541 SW INEZ ST. 4" SITE PLAN' SCALE: I'. 20'-0' FOR OFFICE USE ONLY—SITE ADDRESS: This form is recognized by most building departments in the Tri-County area for transmitting information. Please complete this form when submitting information for plan review responses and revisions. This form and the information it provides helps the review process and response to your project. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ;:f.- Transmittal Letter 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 •www.tigard-or.gov TO: Zr6(11\ DATE RECEIVED: DEPT: BUILDING DIVISION RECEIVE FROM: sg-l••( MAY 2 4 % 6 CITY O► IGARD COMPANY: BUILD G DIVISIQ PHONE: 42-C q,q 2 7o s- B : RE: 9'-1-4/ S 11V / NEz ST. • / . 20 /C QQ 1`i 2J (Site Address) A r ermrt um•er i � �� (Project name or subdivision name and lot number) ATTACHED ARE THE FOLLOWING ITA S: f, Additional set(s)of plans. \/' Revisions: Cross section(s)and details. Wall bracing and/or lateral analysis. Floor/roof framing. Basement and retaining walls. Beam calculations. Engineer's calculations. Other(explain): REMARKS: E (M Q V C S r 12 S Routed to Pe it Technici, : Date: _ 9 J C Initials: Fees Due: Yes • o Fee Description: AmotHv . . 1 )4r1D)t.,„ YcV J ' $ q4— $ $ Special Instructions: Reprint Permit(per PE): ❑ Yes No ❑ Done Applicant Notified: ,v-C , Date: 6/6, Initials: ..j I:\Building\Forms\TransmittalLetter-Revisions.doc 05/25/2012 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit RECEIVER , i 1 , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503- 1 - 03 .tigard-or.gov "rr � 52015 r TO: CITY OF TIGARD (;jrY Ulf oI' II, Building Division '� jLDINc Di 6uILnI���I A RD 13125 SW Hall Blvd.,Tigard,OR 972v1sI�A, ION Phone: 503-718-2439 Fax: 503-598-1960 TigardButl`dingPermits@tigard-or.gov FROM: © Owner ❑ Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) (Mj(JZ Cc�. /� �/�( l -1tK �� Mailing Address: 67)S-6, SW (N EZ .. City/State/Zip: 71 G,4 R.b 01e . '372.2-4 Phone No.: 42j q9 -/ 2-7QT '/oZ5-- !// -0? 7 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). PSI 2o/F - 00/113 Site Address or Parcel#: qF''/ 4 S w oV E2 .1T-, 71G-,(R/ , 0 , Project Name: 51f N Subdivision Name: Lot#: -..rE)PLANATION: \)(/E WOULIQ LIKE. C-0 REI S i 4-CL 7-1161-= pe'of Signature: Date: AO/if/2 0 I Print Name: Nire /d-M 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 Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_092314.doc