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Permit Support Document IL 4 City of Tigard • COMMUNITY•DEVELOPMENT DEPARTMENT V 111 _. Request for Permit Action lv //7 T 1 G A R D 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 TigardBuildingPernits@tigard-or.gov FROM: ❑ Owner El Applicant ❑ Contractor Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: 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 PERMIT (do not cancel permit). Permit#: %, )/.7 vcj 3T Site Address or Parcel#: /65- 5, /` 7cAe 7 Subdivision Name: Lot#: EXPLANATION: / �dJ s.5 "c.,,,;„1,1,f Ake.Gezei /1.) 4-rS, />9€.44-3,t/i „047-,,,7-- /"1/7.e.0.0/ Signature: .� Date: Viz/ Print Name: Vr..Al-- ZA/ • 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 q i7 By .71 Route to Records: Date /'/ , / 7 By 'i Refund Processed: Date? j By 41110 Invoice Processed: Date $ Permit Canceled: Date/ y �/ /7 $y Parcel Tag Added: Date By m I.\Building\Forms\RegPeritAction_ 23 4.doc Building Permit ApplicatRECEIVED Commercial FOR 01 I I( 1. 1 S1: 0\I.1 City of Tigard AUG 16 2017 Received / Permit No.: DateB : ig 4 16a Pao!7vo a 3 111 q 13125 SW Hall Blvd.,Tigard,OR 97223 • Plan R- . Il Phone: 503-718-2439 Fax: 500'11960FDateB : Ai I1 1 Related Permit: T <;A R t) Inspection Line: 503-639-4175 TIGI�I�D Date R :A"y:��•� huffs: ® See Page 2 for Internet: www.tigard-or.gov BUILDING DIVISION Notified/Method: Supplemental Information • _. �� ^Mz+= ,. re„r„q .g ' A3 � �°X .� , } -`Yx a afw � ate u + te „?,, ,., c... zRx..„. a,,- , ❑Ne_w contcti .'''''''''''°'‘' r tA"-5'n �� ��❑�D.teemolitionpt � Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all ►i Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the ,ir j : work indicated on this application. Valuation: $ 0 1-and 2-family dwelling 0 Commercial/industrial ❑Accessory building 0 Multi-family *��` Number of bedrooms: ❑Master builder 0 Other:W/.-5 ...,,„ of bathrooms: -,------,--,,,,-..,?,74' - r ap`'. ' " Total number of floors: g 5 ^ A f New dwelling area: square feet Job site address: (es go S City/State/ZIP: f 4t.o f O 2 c 7 2 Z 4. Garage/carport area: square feet Suite/bldg./apt.#: Project name:DNt JA ? gioo,K, Covered porch area: square feet Cross street/directions to job site:Hyeoc koQ.i Vi 'a ci-As (t j.y4(Jc yw•t f S Deck area: square feet Other structure area: square feet Subdivision: I Lot#: Permit fees*are based on the value of the work performed Tax map/parcel#: Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the nom, • §± , s' h ..--.i'•- ;- ,-,,,, -s, -• ?.....,,,,,q4-7work indicated on this application Valuation: $ t p p 015 0 r�£✓�v alb 0{- t 1Tt.16, _/a.ltl nui�5�^�Q' DF r fi ^(a / Pieta s i9PP' ' S --.114C1-iii-1"1)47°^') Existing building area: square feet 5 F OC (Aeon/it c S�0./41:1-4 • V. ti--rte New building area: square feet t el," -,'�� "- i.A 1 a''`te , - Number of stories: Name: Gift/4-N) yi a-11-0-__ S rz t2.✓1 C 5 Type of construction: Address: b 0 60 S t'° $_s-'a / r? Occupancy groups: City/State/ZIP: (6 fr.v.6 £9L_ 1-7 ZZG -- Existing: 3 . Fax (.ax ), . New:Phone (5D ) S4 ,O ,. f ,z,, -.a - a x". t t ` _ { ` „� "q- ai ,Jr �� ON a „;: s 4 y sRfig ... t-.. t+ �ia � , n .;1,,,r es .7s* ,u.. � 7'. y,4? - � m «: , :.-. ,, ,' ��,.� � 'il Business name: Structural plan review fee(or deposit): Contact name: D 9-2)(1 7 FLS plan review fee(if applicable): Address: eL vs"—e-- C t 6 0 4-",i eYt /4-A- City/State/ZIP: Total fees due upon application: �/ Phone:(5500 5 ) SA 7 8 0 4 3 F ©.(c4 7) 6© `3 S� Amount received: n?1 1. 7 E-mail: + it v L w dQ C 1 Q& W , ,' oitiVtl«l i'r�'At b)LMO,tl ] M _ 3 Commercial and residential prescriptive installation of _ roof-to.mounted PhotoVoltaic Solar Panel System. Business name: Submit •(2)sets of roof plan with conn- '. .etails and fire dep..'. ent access,along ' 1 e 2010 Oregon Address: Solar Installatio ecial .''e checklist. City/State/ZIP: Permit fee(in s plan review $180.00 a• adminis •, - fees): Phone:( ) Fax:( ) State , harge(12%of permit fee): $21.60 CCB Lic.: Total fee due upon application: $201.60 Authorized signature: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Date: O ,Vtzo ( 7 * Fee methodology set by Tri-County Building Industry Print name: ` testi1Service Board. 440 4613T(11/02/COM/WEB) I:\Building\Permits\BUP COM_PermitApp.doc Rev.04/21/2014 CITY OF TIGARD RECEIPT II 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Clean Water Services Site Address: 16580 SW 85TH AVE Receipt Number: 413139 - 10/04/2017 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID BUP2017-00232 Plan Review-Building 230-0000-43106 $718.87 Total: $718.87 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Fund Transfer DHOWSE 10/04/2017 $718.87 Payor: '' 020/7 Or 73'5' Total Payments: $718.87 Balance Due: $0.00 Page 1 of 1