Permit (43) City of Tigard • COMMUNITY DEVELOPMENT DEPART
. EIVrEp
quest REC
for Permit Action din
T'I,;,11.l 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •wu f i 01 l f�?r, yvr,
oh
TO: CITY OF TIGARD j��' �
Building DivisionD
ING D
13125 SW Hall Blvd.,Tigard,OR 97223 IV `� � '
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPern.its@tigard-or.gov
FROM: ❑ Owner
Check(✓)one ❑ Applicant 46 Contractor 113 City Staff
REFUND OR Name:
INVOICE TO: (Business or Individual) VA ei112. 4 LzLv - L., ^-',
Mailing Address: '; (,) , -..\
.,,
City/State/Zip: 0..C , 02- C' 1
Phone No.: --- Lot ,-,
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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 PERMITdo not cancel permit).
Permit#; r t i aim c 0 , �i;.. c
•
Site Address or Parcel#:
k` : 6 -')1 .1 vrt,(i 1,--;\(M
Project Name: \\. --- \--\'\Z/1 Cy , C,,t-- ,t)c,--.:›1 ,.,,),S.,
Subdivision Name: _..
Lot#: .:J
EXPLANATION:
(t;"Signature: , , ' '' . t,-S Date: 1 /..
Print Name: 7
Refund Policy , ,1 /L ,,s
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
7c2; 5t9 -- -5- , _ /y', 561
FOR O} FICE USE ONLY
Route to Sys Admin: Date 7 , I7 By „191 'oute to Records: Date 3 -261-- 4,:c7v,7 —
Refund Processed: Date . ' ?'f By'�. Invoice Processed: Date By
Permit Canceled: Date 2-Vt'? B ��++.�. Parcel Tag Added: Date By
I:\Building\Furrns
\ReVeutAcuon_92314.doc
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r
TIGARD
September 21, 2017 City of Tigard
DR Horton, Inc.
Attn: Emerald Weeks
4380 SW Macadam Ave.,Ste 100
Portland, OR 97239
Re: Permit No. PLM2016-00628
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 15530 SW Applewood Ln
Project Name: Heritage Crossing,Lot 50
Job No.: N/A
Refund Method: ® Check#226146 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 work was not completed. Refund 80% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Z;c46zo--j..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
III
u 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 RequertforPermitAction 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: DR Horton, Inc. DATE: 9/18/2017
Attn: Emerald Weeks
4380 SW Macadam Ave., Ste 100 REQUESTED BY: Dianna Howse
Portland, OR 97239
TRANSACTION INFORMATION:
Receipt#: 409601 Case#: PLM2016-00628
Date: 3/24/2017 Address/Parcel: 15530 SW Applewood Ln
Pay Method: CreditCard Project Name: Heritage Crossing,Lot 50
EXPLANATION: Per applicant's request as work was not completed. Refund 80%of
permt fees.
r,^ ' semf `7iF� s T qq )gym ` as
tfilterr
oer mi ;'(-41',11,� of ‘' F
Plumbin_ Perm: � tr � ''c 4't4'' ,*''.1' 24i6:0000-43101 $58.00
12%State Surchar.a 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNA S/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
' STRATIONNSOCkkw '"r‘04'-i'-'"'". ' '''"
Case Refund Processed: I Date: I / ,1j� By: I
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY TR
III
13125 SW
OF Hall Blvd.IGA,Tigard ORD 97223 RECEIPT
503.639.4171
TIGARD
Project Name: Heritage Crossing, Lot 50
Site Address: 15530 SW APPLEWOOD LN
I Receipt Number: 416291 - 03/23/2018
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
PLM2016-00628
$-64.96
Total: $-64.96
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226146 DHOWSE 03/23/2018
Payor: D R Horton, Inc. $-64.96
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
1111---',.
13125 SW Hat Blvd.,Tigard OR 97223
— 503.639.4171
TTC\RT)
Project Name: Heritage Crossing, Lot 50
Site Address: 15530 SW APPLEWOOD LN
®2lr4v'gc—
I Receipt Number: 409601 - 03/24/2017
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
PLM2016-00628 Backflow Preventer 230-0000-43101
PLM2016-00628 12%State Surcharge-Plumbing $$8.70
100
PLM2016-00628 -0000-24001 $8 70
Minimum Fee Adjustment-Plumbing 230-0000-43101 $41.23
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card
Payor: dr horton inc 000279 ASHI USERO 03/24/2017
$81.20
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD PLUMBING PERMIT
101, Permit#: PLM2016 00628
lm COMMUNITY DEVELOPMENT
Date Issued: 03/27/2017
f C. AT3 L 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S111DA23100
Jurisdiction: Tigard
Site address: 15530 SW APPLEWOOD LN
Project: Heritage Crossing, Lot 50 Subdivision: HERITAGE CROSSING Lot: 50
Project Description: Backflow preventer for irrigation.
Contractor: TRADEMARK LANDSCAPES INC Owner: DR HORTON INC.
PO BOX 2410 4380 SW MACADAM AVE STE 100
OREGON CITY, OR 97006 PORTLAND, OR 97239
PHONE: 503-631-3893 PHONE: 503-222-4151
FAX: 503-631-4737
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 03/24/2017 $31.27
Specifics: 1 12%State Surcharge- 03/24/2017 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment- 03/24/2017 $41.23
Plumbing
Class of Work: OTR
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: / Permittee Signature:
//k‘f /
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.
Plumbing Permit Application
• Building Fixtures 'JF 7
��. l t►u t)r l It l: t a tt,, r
City of Tigard Re<e„�
13125 SW Hall Blvd,Tigard.OR Q Roe e`B A A. /1:. / Penni'\o /
Phone: 503 718 2439 Fax. 5 , 1�/ ...CO '
03 196 Plan Re�xa
I i 4,n+e t t Inspection Line. 503.639.417 DataB�. � Other Permit
y 0 t I I(”f t- z Date Reads By See Page ZOl G SOUS .t_
Internet. w1NA%tigard-or.gov i r I S3 Panes Ifnn
TYPE
�b ��0 1" l i¢ 'vi y'oti6ed�tvtnbod: Supplemental Information
New construction
FEE* SCHEDULE
❑Demolition For special info on use checklist
❑Addition/alteration/replacement 0 Other: Descnpnon Qty. j Ea. ( Total
New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(1)bath
31.70
el 1-and 2-family dwelling ❑Commerciallindtutnal SFR(2)bath 437 78
a
❑Accessory building 0 Multi-famil} SFR(3)bath 500.32
0 Master builder Other Each additional batnkitehen 25.02
-
JOB SITE INFORMATION AND LOCATION Site utFire utilnklsr( sq.t1.1 Page 2
ilities:
lob site address: J t5 - CS� �1 )„ ) / -f Catch basin or area drain 1 g 76
Cityistate/ZiP: Tigard, OR 97223 �'-# ���(� (��y�� on'vtielt,leach line.or trench drain 18.76
Footing drain(no.linear ft.:
Suite/bldg/apt.no.: I Project name V\th (xo3 _Jno ...1 Page 2
Cross street:directions to job site: i'i J Manufactured home utilities s0 03
Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft:. i Page 2
Storm sewer(no.linear ft.: __-t Page 2
Subdivision: \ Water service(no linear ft,...__) Pae 2
Lot no.:ljry ' Fixture or item: g
Tax map/parcel no.: Backflow prevents
1 31.27
DESCRIPTION OF WORK Backwater valve 12.51
New SFR Clothes Hasner 25 02
Dishwasher 25.02
Drinking fountain 25.02
Ejectorstsump 25 02
illj PROPERTY OWNER 0 TENANT Expansion tank
12.51
Name: DR Horton Inc. Fixture/sewer cap 23 02
Address:4380 SW Macadam Ave Suite 100 Floor drain floor smk hub 25.02
CitylState/ZIP Portland,OR 97239 Garbage disposal 25.02 'Hose
Phone:(503)222-4151 Fax:( ) Ice maema bibker 12.51
0 APPLICANT 15 31
CONTACT PERSON Intereeptodgresse trap 25.02
Business name: DR Horton Inc. Medical gas(value S
)
Page 2
Contact name Emerald Weeks Primer
12.51
Address:4380 SW Macadam Ave Suite 100 Roof drain(commercial) 1�51
Sink/basin/lavaton
City/State/ZIP: Portland, OR 97239 62 54
solar units(potable water) 62.54
Phone.(503 )222-4151 X1107 I Fax::( ) Tub/shower/shower pan 12.51
E-mail: esweeks@drhorton.com ate r 25 02
CONTRACTOR Water closet 25.02
Business name'I'rademark Landscapes Inc Water heater 37 52
Address: Water piping'DWV 56.29
PO Box 2410 Other:
City/State/Z1POregon City, OR 97045 23°"
Subtotal
Phone:(503) 631-3893 I Fax (C031 G 3/-y737 Minimum
permit fee: £72.50
CCB Lic.: j /3 S-3 - ' Ptutnbintt.ie.,no.: - 1-1 Plan review i25%of permit feel
'y` c.+.
Authorized signature: „ State surcharge(12%of permit fee)
Print name: TOTAL PERMIT FEE
�1 -JE. i/4;: I Date:2016 1 This permit application expires if a permit is not obtained within 180 days
abet it bass been accepted as complete.
"Fee methodolotn set bt Tri.Counn Building Industry Service Board.
t Buudine PernsnsPt\tU.Pe rMApp.co 1001 09
440-46 107110 OS COM wE81