Permit Support Document (29) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action
T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD / 0I
Building Division .
13125 SW Hall Blvd.,Tigard, OR 97223 .//G�j2 ,�579- -
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: /
INVOICE TO: (Business or Individual) AIA (. / .1p E.-f.,6 p4,o>
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
7CANCEL/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#: &()Pao/7-006'7(0
Site Address or Parcel#: /o23C5D &AD lig ,41z)e--
- //6.9- , O� 57a-V-'5
Subdivision Name: Lot#:
EXPLANATION: p„,...,14 Coe n cm /L. 'gdr7 iek,a 53 L.,,...rzt_
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it ,,JA--t.ly `D e se ., AcD. ATO 5_ _f:,'7% Aroi Alii -= --
Signature: i Date: c2
Print Name: i ±46/E__ ,,9.
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date 87 /7 By Route to Records: Date S /p /7 By
Refund Processed: Date /t/ff• By, Invoice Processed: Date By
Permit Canceled: Date 3/j /`7 Byt94,-- Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_0 231 .doc
71 Accumulative Sewer Tally
Tenant Name: Landmark Ford SWR# 2017-00076 VOID
T 1 GA R D Site Address: 12300 SW 68th Ave PLM# 2017-00053
Parcel#: 2S 101 AA00100
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
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 1 2 1 2
-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 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 1 2 1 2
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 0 0 0
� •
I
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 5 30 5 30
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 8 40 8 40
Current Fixture Value 40 divided by 16= 2.500 Current EDU 1 EDU= $5,300.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 40 divided by 16= 2.500 over (under) $ 13,250.00
Enter EDU Change Here 2.500 *
*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:
Authorized Name/Signature: Debbie Adamski Date: 2/27/2017
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:\Building\Sewer Tally\SewerTallySheet_5300_070116.xlsx