Permit 0 1
CityofTigard • COMMUNITY DEVELOPMENT DEPARTMENT 9A0f.....„
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Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW H Blvd.,Tigard,OR 97223
Phone: -718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: Owner ❑ Applicant p Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) /20/C/4-Z-`- 7 i L' 7SFA)
Mailing Address: AZ 3i? L)7iJ 7 2 7� ��
City/State/Zip: "776
Phone No.: v � 5. E' �
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
ANCEL/VOID PERMIT APPLICATION.
0 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: AGS )!!v—cX)31i:4o
Site Address or Parcel#: /5-6'20 5 7 y
Project Name: /
Subdivision Name: Lot#: )
EXPLANATION: ,-.4 cf y L (/2C�J�'TG-�jl� /' ?��2/c..)—cr. 7.7
Signature: / ew � //moi` Date:
Print Name: / 77) 1•/,�
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 7) (; —
— � � _ 4 7y
FOR OFFICE USE ONLY
Route to Sys Admin: Date y /if B :7-,, Route to Records: Date 4, /1 B . .
Refund Processed: Date9 /Q / / Invoice Processed: Date By
Permit Canceled: Date-//9 �(i By i rcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 923 4.doc
11111 .
TIGARD
City of Tigard
September 17,2018
Ronald Layton
15630 SW 79th Ave
Tigard, OR 97224
Re: Permit No. PLM2016-00346
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15630 SW 79th Ave
Project Name: Layton
Job No.: N/A
Refund Method: ® Check#229753 in the amount of$64.96.
❑ Credit card "return"receipt in the amount of$
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 contractor pulled a duplicate permit. 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
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: Ronald Layton DATE: 9/10/2018
15630 SW 79th Ave
Tigard, OR 97224 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 404781,404786 Case#: PLM2016-00346
Date: 6/30/2016 Address/Parcel: 15630 SW 79th Ave.
Pay Method: Check Project Name: Layton
EXPLANATION: Per applicant's request as contractor pulled a duplicate permit. Refund 80%of permit
fees.
MPTITWEIVITrAlrsrgym te .
a , 04": tl6x 45 kM
Plumbin: Permit 230-0000-43101 $58.00
12%State Surchar.e 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGN /D TE:
If 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
Case Refund Processed: Date: '/y2/f, By: z,A '
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
f CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit#: PLM2016-00346
TFIGAR. 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/30/2016
Parcel: 2S112C D02000
Jurisdiction: Tigard
Site address: 15630 SW 79TH AVE
Project: LAYTON Subdivision: DURHAM ACRES Lot: 14
Project Description: 60 ft.of sanitary sewer.
Contractor: PORTLAND ROAD&DRIVEWAY CO INC Owner: LAYTON, RONALD J
10500 SE JENNIFER ST 15630 SW 79TH AVE
CLACKAMAS, OR 97015-9511 TIGARD, OR 97224
PHONE: 503-650-5006 PHONE:
FAX: 503-650-8022
FEES
Quantity Description Date Amount
60 If Sanitary Sewer 06/30/2016 $62.54
Specifics: 10 ea Minimum Fee Adjustment- 06/30/2016 $9.96
Plumbing
Type of Use: SF
Class of Work: ALT
Type of Const:
Occupancy Grp:
Stories:
Total $72.50
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 952-001-00•:. You may obtain a copy• rules
or direct questions to OUNC by calling 503 •:7 or 1.84
Issued By: 10,
Signature: V AP.
Call 503.6 75 by 7:00 a.m.for the next available nspection 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 r. o
_.../,, 4 •
Building Fixtures , t
a FOR OFFICE USI. ONLI
City of Tigard Received r 3v /0 f �!
r• Date/By: (D Permit No.:
114 in 13125 SW Hall Blvd.,Tigard,OR 97223 -C �L
t 1' �l Plan Review AiT,20/�
_ Phone: 503.718.2439 Fax: 503.598.1 ��>> 1 �t Date/By: Other Permit No.:
Inspection Line: 503.639.4175 ' 3�
T I G/�R D ;' Date Ready/ByJur : ® See Page 2 for
Internet: www.tigard-or.gov : ,' Notified/Method: / Supplemental Information
TYPE OF WOE I DIV iSk"
.
FEE*SCHEDULE
❑New construction �Demolition
For special information use checklist
Description I Qty. I Ea. I Total
Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath 312.70
❑ 1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building 0 Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
0 Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
JOB SITE INFORMATION AND LOCATION Site utilities:
Job site address: /5-63 t. 5 t. ,f 79.r/71 /1z/e-
/ Catch basin or area drain 18.76
City/State/ZIP: 6 0 , d 2 92 ZZy Drywell,leach line,or trench drain 18.76
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name:,e_,4-y'3<) /23i(. c 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 6;2.
Storm sewer(no.linear ft.:_) l Page 2 /'
Water service(no.linear ft.:_) Page 2
Subdivision: PVPf.(//jyl%�-5 I Lot no.:
/71 Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
,- ESCRIP'� NOF * r Backwater valve 12.51
Clothes washer 25.02
620 . ,5-74.-- s474/,..-7/23.y =P�-.t,.."- Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
x .,.- r PROPERTY OWNER I 0 TENA ' Expansion tank 12.51
Name: /2 )It-L,0 d ,4-7,719%-) Fixture/sewer cap 25.02
Address: /`j Gap 5ti ) 2,• /9-7,,e------ Floor drain/floor sink/hub 25.02
Garbage disposal 25.02
City/State/ZIP: 776.4720 d �j' 2 2-2/.
Hose bib 25.02
Phone:( 05) C6 S--5233c Fax:( ) Ice maker 12.51
❑ APP C `❑ CONTACT PERS 1 Interceptor/grease trap 25.02
Business name: ` ,s, Q6ral� Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax: :( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
P.... /k---D
M
Water closet 25.02
�T Water heater 37.52
Business name: DO��,s�,.},/) � , 0/21 F'L=Zn 4)/ Water piping/DWV 56.29
D
Address: d11 a,1)( f �7 `/ _ Other: 25.02
City/State/ZIP:` Chi C ,r (-_-)R. c9 -->0�12 Subtotal
Phone:( 3) C� Fax:( ) Minimum permit fee: $72.50
��" 6� ^ q Plan review (25%of permit fee)
CCB Lic.: ) �oj /tv 1 Plu;-g Lic.no.: A ?? 7/,/,?
State surcharge(12%of permit fee)
Authorized si re' TOTAL PERMIT FEE $l.O v
Print nam ,e- Date: Jv A 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.
1:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(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 $121.90
Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69
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
Valuatie : Permit Fee:
Storm&Rain Drain-1st 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50
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 Fee(ear''' 'otai each clu additional$10,$100.00. or fraction thereof,to
h Pr 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 including$50,000.00.
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*. Pl Review for Plumbing lostalladqns
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for C Added e/ Please check all that apply.
Work Performed: al's ❑ Any new commercial building with water service 2"and
Baptistry/Font greater,except systems designed and stamped by licensed
Bath: -Tub/Shower engineer.
-Jacuzzi/Whirlpool
Car Wash: -Each Stall 0 New exterior plumbing site utilities for any complex structure
as defined in OAR918-780-0040.
-Drive Thru
Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities.
Dishwasher: -Commercialirator 0 Any multipurpose fire sprinkler system.
Domestic 0 Any complex structure as defined in OAR918-780-0040.
Drinking Fountain
Eye Wash Submit 2 sets of plans with any of the above.
Floor Drain/sink: -2"
3" Isometric or Riser Diagram
4"
0 Isometric or riser diagram is required for new buildings
-Car Wash Drain
that meet the qualifications above.
Garbage -Domestic non-food
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
Sink: -Lav/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