Permit (75) 0 0
IL, 4City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT' 1
27--/icf- R#I4----
:r11 2 Request for Permit Action V
TIGARD, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-01 m goy,
TO: CITY OF TIGARD MAY4 2018
Building Division CITY OF TIGARD
13125 SW Hall Blvd.,Tigard,OR 97223 BUILDING DIVISION
Phone: 503-7 -2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: caner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: ci T ( (1 r (� /�����
INVOICE TO: (Business or Individual) /' - U c77\/ -'
Mailing Address: °1 (s'L Lf.0 5 0/) ,#‹ L-
i 1611-r0 , OP 9 ).1
City/State/Zip:
Phone No.: ,. .-- Qi Ncc. - 1 007
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).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CON it e _ e " d . IT do not cancel permit).
Permit#: 12Z/12,06)-7.-- 003K5 '' ' // /—C-C
Site Address or Parcel#: II 1 / Orr 0141
144 L
C.-.. z
Project Name: (J 0 / , V .50.1\/
Subdivision Name: Lot#:
--- , .,_
EXPLAN ON: i 41J -741 f
/7,7 tA ; '
Signature: - �L�,o / _ Date: 5 ' / •"---","��
Print Name:
Refund Polity GltS7�pJEI2, (is A/c �'c3n/r�/�C �E4. .6 !mak,-1 �
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
702, .,.‹Pt Cz) /Y -5c)
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FOR OFFICE USE ONLY
Route to Sys Admin: Date 5 ti v By Route to Records: Date 2'i /r B
Refund Processed: Date '..r '
2Z !d"" By�� Invoice Processed: Date By
Permit Canceled: Date e,/2.y1/S. -1,*B r Parcel Tag Added: Date B
I:\Building\Forms\RegPemiltAction_062314.doc y
7" m M
TIGARD
City of Tigard
June 28, 2018
Kurt Johnson
9640 SW Darmel Ct.
Tigard, OR 97224
Re: Permit No. PLM2017-00385
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9640 SW Darmel Ct
Project Name: Johnson
Job No.: N/A
Refund Method: ® Check#228933 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 he could not find a contractor to dig under the
street to connect to sanitary sewer. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
44;4701(--'
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
.11hi
City of Tigard
T I G A R D 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: Kurt Johnson DATE: 6/22/2018
9640 SW Darmel Ct
Tigard, OR 97224 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 412967 Case#: PLM2017-00385
Date: 9/25/2017 Address/Parcel: 9640 SW Darmel Ct.
Pay Method: CreditCard Project Name: Johnson
EXPLANATION: Per applicant's request to cancel permit because he could not find a contractor to dig
under street to connect to sanitary sewer. Refund 80%of permit fees.
Vie' p 4 f"8 t t :114'x - R i t !' t ' lL `t
lYl w' ° `, , � I µs. ;, # •a Y i 1' xe ,:'. i
Plumbin• Permit Fee 230-0000-43101 $58.00
12%State Surchar:e 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNAT S/DATE:
If under$5,000 Professional Staff //
‘11111fir 10"
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
'<Foitg IDEM QST
Case Refund Processed: Date: .3/2-9A 9 1 By: A
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD PLUMBING PERMIT
P av COMMUNITY DEVELOPMENT Permit#: PLM2017 00385
T f GAR D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/25/2017
Parcel: 2S 111 CA 13500
Jurisdiction: Tigard
Site address: 9640 SW DARMEL CT
Project: Johnson Subdivision: DARMEL NO.2 Lot: 37
Project Description: 100 FT sanitary sewer.Connecting existing house to sewer.
Contractor: OWNER Owner: JOHNSON, KURT D
KURT JOHNSON 9640 SW DARMEL CT
9640 SW DARMEL CT TIGARD, OR 97224
TIGARD, OR 97224
PHONE PHONE:
FAX:
FEES
Quantity Description Date Amount
100 If Sanitary Sewer 09/25/2017 $62.54
Specifics: 1 12%State Surcharge- 09/25/2017 $8.70
Plumbing
Type of Use: SF 10 ea Minimum Fee Adjustment- 09/25/2017 $9.96
Plumbing
Class of Work: ALT
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 ob -in a :Ty f the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
C (----'sIssued By: Permiffee Signature: r /
...4.........2
, eil____
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 -, FOR OFFICE USE ONE1
City of Tigard " c, Received / �/�J/ /y}7
' ` e y. A 7 ) / Permit /7 Lf/J
1111
13125 SW Hall Blvd.,Tigard,O 73
Date/By: v+��,`
■ Phone: 503.718.2439 Fax: 50 960 Plan Revie 17 60,g 0
Date/By: Other Permit No.: 0
Inspection Line: 503.639.4175
1 1 G A R D 5 ��\ Date Ready/By: J H See Page 2 for
Internet: www.ttgard-or.govj @
� ;� Notified/Method: /�f Supplemental Information
TYPE OF WORK l► 1 it,
_ THEE* SCHEDULE
❑New construction [tt-', .litio - i} , 1 For special information use checklist
1 Descri•rion =MI Ea. Total
❑Addition/alteration/replacement ri011ipt% New 1-2-family dwellings(includes 100 ft.for each utility connection)
' �-, 'CATEGORY O
OF CONSTRUCTION< (1)bath SFR�� E. � ti � 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
❑Master builderEach additional bath/kitchen 25.02
0 Other: Fire sprinkler( sq.ft.) Page 2
"• 4OB`SITE INFORMATION AND LOCATION ,.. Site utilities:
Job site address: D . i 6� c I Catch basin or area drain 18.76
L Drywell,leach line,or trench drain 18.76
City/State/ZIP: 1 ) 0 vv►►�, l/ C., � 7 Ca, c.,,
1 Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name: J 27 `�' L.c5 O A/ Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.://.0) / Page 2 Ls.Z 5-y
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision: I Lot no.: Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
D'E'S '''''''IO OF*? Backwater valve 12.51
Clothes washer 25.02
Dishwasher 25.02
/10(,.1 .r F1-1/ s'L /5" ��A Drinking fountain 25.02
Ejectors/sump 25.02
PROPERTY OWNER , TENANT Expansion tank 12.51
Name: y9-. F 0S 6 2-\/"".2-\/"". Fixture/sewer cap 25.02
Address: 9(tZ f Q 5 0/ r J r /6 L -_JFloor drain/floor sink/hub 25.02
� Garbage disposal 25.02
City/State/ZIP: .6 r')0 c� 72 , 4C� Hose bib 25.02
Phone:( ' '� D .-- Fax:( ) Ice maker 12.51
APPLICANT ;❑ CONTACT PERSON Interceptor/grease trap 25.02
Business name: C� RS _� Medical gas(value:$ ) Page 2
6� 1� 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
CONTRACTOR Water closet 25.02
Water heater 37.52
Business name:
ejwi- Water piping/DWV 56.29
Address: Other:
25.02
City/State/ZIP: Subtotal 6).52f
Phone:( ) Fax:( ) Minimum permit fee: $72.50
?)_sem
CCB Lie.: 1 Bing Lic.no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee) sr,,7a
Authorized signature:
` TOTAL PERMIT FEE Fs'
Print name: /'j
/ ) ir
`1 0( J r p ate: t1 l7C `5-J I This permit application expires if a permit is not obtained within 186 days '
l / ✓✓✓ after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I:\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:
q a fe notal Square Footage!x I'; 'mit 'ee: -
bite�fit>dites .r ''• -' �
Footing drain-l5`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 42.,5-ir 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
`�Vai�;ation. Peri>r>"rit'F�e: A
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
• ' oral each additional$100.00 or fraction thereof,to
Other Inspections or Fees, x., „ 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
each additional$100.00 or fraction thereof.
(minimum charge-1/2 hour)
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to . t
accurately report fixtures could result in increased sewer fees*. Ply Review for Plumbing n,stall- , ns
Quantity by Fixture Type Plan review is required for any of the following.
Fixture Type for Replace/ Please check all that apply.
Work Performed: Capped Added, Relocate
0 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 0 New exterior plumbing site utilities for any complex structure
Car Wash: -Each Stall as defined in OAR918-780-0040.
-Drive Thru
0 Medical gas and vacuum systems for health care facilities.
Cuspidor/Water Aspirator
-Commercial 0 Any multipurpose fire sprinkler system.
Dishwasher: - ommerommerc El Any complex structure as defined in OAR918-780-0040.
-D
Drinking Fountain Submit 2 sets of plans with any of the above.
Eye Wash
Floor Drain/sink: -2"
3» Isometric or l se Diagra n
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 MachiRefrig.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