Permit (10) 0 1 0
NCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ki,
Request for Permit Action `�'7/' ' d(OI `"
TIGARD 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: 0 Owner 0 Applicant ❑ Contractor
Check(✓)one City xi Staff
REFUND OR Name:
INVOICE TO: (Business or Individual) S` +� ,AL�U� 0 do e.Q J 1 --€ S
Mailing Address: G74/4 6t..0 1 6f}-2'b 'r- *Lop
City/State/Zip: Y 142T I oe q 7 a-a-3
Phone No.: 503_ Zo 3c1- 390 f
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
AREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ITo2CO 17 --d,noceo
Site Address or Parcel #: q7 aVJsto Tb A-&....-7, 6:T-:- �--e._4 -j
Project Name: e LC-1 C 7T 6-ipratO,5c-k---1-6
Subdivision Name: 1J1
Lot#: A1/4-
EXPLANATION: f e 5 r o 0_,„,„)-112.01 o 20Ly PieH fr. /36t
G�2aS,oA) 6-0, -1i2-oL?`o g� u�J� E2 �uPaol7-Dol Z ftu__Po_sN,
Ect, 1,1b
Signature: iL
Date: '// l
I.
Print ( /l1 17
Print Name: Ep,p5 1e_ A--T- Pt-M 5 k1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 4 � 11 B, . to Route to Records: Date t/ 7 /; B
Refund Processed: Date yl/17 By ,i1,12 Invoice Processed: Date y I
Permit Canceled: Date By
�/' /7�/7 By :��* Parcel Tag Added: Date By
I:\Bui]ding\Forms\RegPemmitAction_0 2314:doc
-
TIGARD
City of Tigard
May 2,2017
SAS Balancing Services Inc.
Attn: Deron Snyder
9744 SW Tigard St., #100
Tigard, OR 97223
Re: Permit No. SIT2017-00006
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9744 SW Tigard St., #500
Project Name: Mario's Auto Repair
Job No.:
Refund Method: ® Check#224428 in the amount of$473.30.
0 Credit card "return"receipt in the amount of$
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): Erosion control only permit not required as fees for erosion control were
collected under demo permit BUP2017-00074. Refund 100% 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
N 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 forPermit 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: SAS Balancing Services Inc. DATE: 4/17/2017
Attn: Deron Snyder
9744 SW Tigard St., #100 REQUESTED BY: Dianna Howse
Tigard, OR 97223 DA
TRANSACTION INFORMATION:
Receipt#: 409666 Case#: SIT2017-00006
Date: 3/28/2017 Address/Parcel: 9744 SW Tigard St,#500
Pay Method: Check Project Name: Mario's Auto Repair
EXPLANATION: Erosion control only permit issued in error;fees collected under demo permit
BUP2017-00074. Refund 100%of permit fees.
- 7,- r,
!,° 3 * 3�re r
`
� � ' y3 '� ryT; 6 4 .� 2±1�a� ,
Erosion Control Onl 80
100-0000-43134 $472.80
Info Process/Archivin• 230-0000-43135 .50
TOTAL REFUND: $473.30
APPROVALS: SIG TURES DATE:
If under$5,000 Professional Staff /1
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
�. -POR-TI
Case Refund Processed: I Date: c"z/A3//cr- I By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
11,,,,,, .., CITY RD
RECEIPT
'- 13125 SWOF Hall Blvd.TIGA,Tigard OR 97223
503.639.4171
TIGARLD
Project Name: ELLIOTT
Site Address: 9744 SW TIGARD ST 500
/�� Cuf1:6
I Receipt Number: 415774 -
02/23/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
SIT2017-00006
$-473.30
Total: $473.30
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Check CASHIER ID RECEIPT DATE RECEIPT AMT
224428 DHOWSE
Payor: SAS Balancing Services Inc. 02/23/2018 $473.30
Total Payments: $473.30
Balance Due: $473.30
Page 1 of 1
INCITY OF TIGARD
■ 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
- 503.639.4171
TIC.;AU I)
Of(64"44--
1 Receipt
64" 4-
Receipt Number: 409666 03/28/2017
CASE NO. IFEE DESCRIPTION REVENUE ACCOUNT NUMBER
SIT2017-00006 PAID
Erosion Control Only 100-0000-43134
SIT2017-00006 Info Process/Archiving-Sm$0.50(up to $470.50
11x17) 230-0000 43135 $0.50 -
�
Total: $473.30
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 3844
Payor: SAS Balancing Services Inc. BTAGGART 03/28/2017 $473.30
Total Payments: $473.30
Balance Due: $0.00
•
I
F
Page 1 of 1
1 Building Permit Application si /7 VQH'
Site-Wier-4 EA05/0/0 C'_0/J- 24 z.. OI.)L,
FOR OFFICE l SF.O L1
IAICity of Tigard Received
13125 S W Hall Blvd.,Tigard,OR 97223 Date/By: ,3,7 Q�yy17 r Permit No.: 4` /71 j
Phone: 503.718.2439 Fax 503.598.1960 s `; Plan Review 1f '
www.tigard-or.gov
Ins ection Line: 503.639.4175 , .1 ., Date/By: Other Permit:
U A R L) p ; Date Ready/By: )u�ric:^
Internet ',) or ,Notified/Method: '7:4, f Fd See Page Supplemental nf
T I
2
f
1Information
TYPE OF WQ L1' r ,,,;‘,1"-- .
\ `e10REQUIRED DATA:I-AM)2-FAMILY DWELLING
❑New construction '%1]DeMO tuirt ' Permit fees*are based on the value of the work performed.
❑Addition/alteration/replacementIndicate the value(rounded to the nearest dollar)of all
0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
0 1-and 2-family dwelling Cottercial/industrial Valuation: $
mr
ElAccessory building ❑Multi-family Number of bedrooms:
173Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 1.719 vi,1 ^, ` cid Si': New dwelling area: square feet
City/State/ZIP: —r, q
/ Q X23 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name:
maw;0%s A,StD Covered porch area: square feet
Cross street/directions to job site: —�
6r"� ` Deck area: square feet
Other structure area: square feet
Of GW G:CPC
Subdivision: REQUIRED DATA:COMMERCIAL-USE CHECIKi IST''
l Lot no.: Permit fees*are based on the value of the work performed.
Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all
DESCRIPTION OP woRK equipment,materials,labor,overhead,and the profit for the
work indicated on this application.
C'<A,h,ns Ulf) bu'rtrit P, „k 6a.`a`„3. Valuation: $
Existing building area: square feet
New building area: square feet
❑ PROPER' ' OWNER
I %TENANT Number of stories:
Name: ....— f.1.1,”' 1
.1 ��o `'t`�e -f Ser S rGw(„,`V9 pJ�iU1, _cType of construction:
Address: e fl y y s W -.et I 1 st, l 0
I N Occupancy groups:
City/State/ZIP: -'rf% , to�2�
1 Existing:
g
(�'� 31.-3�0� Fax:( )
New:
0 APPLICANT -Si CONTACT.PERSON '
Business name: NOTICE
All contractors and subcontractors are required to be
Contact name: cr, .Sb‘ 444-, licensed with the Oregon Construction Contractors Board ,
Address: (1.144 SW—1.,,,_ �a a under ORS 701 and may be required to be licensed in the
jurisdiction in which work is being performed.If the
City/State/ZIP: —fr,` ,„) d p 2'1-- applicant is exempt from licensing,the following reasons
7
Phone:( 03) riag- 34p� Fax::( ) apply:
E-mail:
CONTRACTOR
Business name: Z/
Address: V(4. BUILDING PERMIT FEES*
(Please refer to fee schedule
City/State/ZIP: Structural plan review fee(or deposit):
FLS plan review fee(if applicable):
Phone:( ) I Fax:( )
CCB lie,: Total fees due upon application: ,
Authorized signature: Amount received:
-- --- This permit application expires if a permit Is not obtained
Print name: Date: within 180 days after It has been accepted as complete.
* Fee methodology set by Tri-County Building Industry
Service Board.
L\Building\Petmits\SIT-PermitApp.doc 08/02/2016
440-4613T(11/02/COM/WEB)
CITY OF TIGARD SITE WORK PERMIT
PPermit#: SIT2017-00006
COMMUNITY DEVELOPMENT
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/28/2017
T Egan L Parcel: 2S102BA00501
Jurisdiction: Tigard
Site address: 9744 SW TIGARD ST 500
Project: ELLIOTT Subdivision: None Lot: None
Project Description: Erosion control only.
Contractor: Owner: ELLIOTT, JAMES R&SHERRY D
PO BOX 570
EAGLE CREEK, OR 97022
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Erosion Control Only 03/28/2017 $472.80
Info Process/Archiving-Sm$0.50(up to 03/28/2017 $0.50
Type of Use: COM 11x17)
Class of Work: OTR
Project Valuation: $0.00
Site Specifics:
Excavation Volume: cu.yd.
Fill Volume: cu.yd.
Impervious Surface: sq.ft.
Engineered Fill: Soil Report Required:
Paving: Grading:
Landscaping: Site Prep:
Storn Drains: Retaining Wall:
Fire Underground: Accessible Parking:
Fence:
Total $473.30
Required Items and Reports(Conditions)
1 Ersn Cntrl 503-639-4175
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:
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.
' Building Permit Application
SiteEk0510'O CD z.. ONJC.,y FOR OFFICE FSE ONLI
City of Tigard
Date/Bea /t'/i1 1 'erma lo.: .. -, •I r.,VIM
13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
111 Phone: 503.718.2439 Fax: 503.598.1960 +.. Date/B : Other Permit:
Inspection Line: 503.639.4175 ,o i.. - !., !- Date Ready/By: Jwis: ® See Page 2 for
T 1( ARD Internet: www.tigard-or.gov ,, to Notified/Method: }.1 , Supplemental Information
TYPE OF WORI %-,:: n v4 REQUIRED DATA:1-AND 2-FAMILY DWELLING
a �
❑New construction De>xtdf.tlort Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $
❑ 1-and 2-family dwelling Comtttercial/industrial
ElAccessory building 0 Multi-family Number of bedrooms:
❑Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: /710 vl-v .--,, ' 44-11 New dwelling area: square feet
City/State/ZIP: 11,Gsfreac Q 9�2_23Z3 Garage/carport area: square feet
I
Suite/bldg./apt.no.: Project name: rv "t O.1 A ita Covered porch area: square feet
Cross street/directions to job site: t_ Deck area: square feet
Other structure area: square feet
ii i
of t ,,ll 4`ift.. REQUIRED DATA;COMMERCIAL-USE CHECKLIST '
Subdivision: I Lot no.: Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
Ci .,h 6// ItiL Valuation: $
E0.�� U� 1,--"T.-1- tee
5 Existing building area: square feet
New building area: square feet
0 PROPERTY OWNERfl+TENANT Number of stories:
Name: .."3--> ®,,,‘ "c. -,, C,ki cO lief• c.,— Type of construction:
Address: en 9 t s w ti`, J O ja Occupancy groups:
City/State/ZIP: 1 c , D& V7 2 -3 Existing:
Phone:(So 3) Gag-yip( Fax:( ) New:
0 APPLICANT 'E] CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name:
a.rro Sh a;r— under ORS 701 and may be required to be licensed in the
Address: Cr-)14 Li sw—r 140A i`, VE. 18 a jurisdiction in which work is being performed.If the
t d 22
i apply:a ppicant is exempt from licensing,the following reasons
City/State/ZIP:
or- )7 3
Phone:( ;)'3) Caq,_ 1 crg Fax::( )
E-mail:
CONTRACTOR
Business name: /1/� BUILDING PERMIT FEES*
(Please refer to fee schedule)
Address:
Structural plan review fee(or deposit):
City/State/ZIP:
FLS plan review fee(if applicable):
Phone:( ) Fax:( )
Total fees due upon application:
CCB lic.:
. _...... Amount received:
Authorized signature: .,-----'"*". This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Date: * Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\SIT-PermitApp.doc 08/02/2016 440-4613T(11/02/COM/WEB)
City of Tigard: Site Work Permit Checklist
Page 2-Supplemental Information
Commercial,Multi-Family and One-and Two-Family Dwellings:
No permit is required if fill is less than 50 yards (5 dump truck loads),or less than 3 feet deep and will
not be supporting a structure. If a building will be constructed on the fill, it must be engineered fill. If
fill is in a flood plain, drainage way, or wetland,the applicant must apply for a sensitive lands review
(SLR).
Please complete all items below,unless otherwise noted.
Excavation Volume: a4 cu.yds.
Grading Volume:
(Soils report required for>5,000 cu.yds.) cu.yds.
Fill Volume:
(Fill exceeding 12"in depth shall be compacted to
90%of maximum density) cu.yds.
Retaining structure? (Check one) ❑ Rock
❑ CMU
EJ Concrete
❑ Other:
*Total new impervious area including all buildings,
sidewalks, and paving: sq. ft.
Site Utilities Plumbing Work:
Complete the Plumbing Permit Application for site utilities plumbing work.
Plans Required: See"Site Work Permit Application-Plan Submittal Requirements"attached.
The following must accompany this application:
❑ Site Plan with Vicinity Map showing ADA ❑ *Parking(including ADA)and Lighting
compliance Plan
❑ Grading Plan and details ❑ *Landscaping Plan
❑ Erosion Control Plan and details ❑ Soils Report(if required)
❑ Retaining Structures
*Does not apply to One-and Two-family dwellings.
Plan Submittal: Permit Fee:
TYPE OF SUBMITTAL #of Plans Valuation: Permit Fee:
(New,Additions or Required at $.00 to$500.00 $51.09 minimum permit fee
Alterations) Submittal $500.01 to$2,000.00 $51.09 for the first$500.00 and
$2.69 for each additional$100 or fraction
Commercial 3 thereof,to and including$2,000.00.
$2,000.01 to$25,000.00 $91.44 for the first$2,000.00 and
Multi-Family R-1 Occupancy 3 $10.76 for each additional$1,000 or
fraction thereof,to and including
$25,000.00.
One-&Two-Family Dwelling 3 $25,000.01 to$50,000.00 $338.92 for the first$25,000.00 and
$8.06 for each additional$1,000.00 or
fraction thereof,to and including
$50,000.00.
$50,001.00 to$100,000.00 $540.42 for the first$50,000.00 and
$5.38 for each additional$1,000.00 or
fraction thereof,to and including
$100,000.00.
$100,000.01 and over $809.42 for the first$100,000.00 and
$4.49 for each additional$1,000.00 or
fraction thereof.
I:\Building\Permits\SIT-PermitApp.doc 08/02/2016 2