Permit (65) -RECEIVED
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City of Tigard • (:OM\n.TNI 1,N l)l:\ l;l,OPI\WNT DI;P.\RV ,O I 0
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Request for Permit Action
IN
BUILDING DIVISION
71 G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.g-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 /p
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPcrmits@tigard-or.gov
FROM: n Owner [11 Applicant n Contractor ❑ City Staff
Check ✓)one ��
REFUND OR Name: S ei�,—AP( )
INVOICE TO: dioxin,,,„r Individual) Vk'``�, • , \1� ` i \ t /,_ ` /� V
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City/State/Zip: TIC' '1 a ( f. . jr (11/1
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Phone No.: 00 - (,e,
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 COIAPCTON.
REFCANL:NDEL/VPERMDITPERFEEMIST(attacPhLIcopA\-oIf original receipt and provide explanation below).
INVOICE FOR FEES DL'E (attach case fee schedule and provide explanation below).
E REMOVE./REPT,ACE CONTRACTOR ON PERMIT •_ e _- • : • (•'t .
Permit#: a.:.v ammostmo _tar • .. r.,b - 40. C ,
Site Address or Parcel #: WDUCO Svx) lS.-\\\ RvitaLksz
Project Name: 06.0„ A1Lr SXvI ekz CP" l �{„
Subdivision Name: Lot#:
EXPLANATION: 1,, A_; , t: . •— . 1 .i ►! ! 0.$ • ,li_,r.► ,k.
Signature: 4 a ,- I .0jjw Date: (DWI 'i 0
Print Name: \ q n • zscx,
Refund Policy
1. The cin's Co,nnrunit) Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80"i;of the application or plan review tee when all application is withdrawn or canceled before review effort
has been expended.
• Not more than 8(Mi of the application or permit tie for issued permits prior to any inspection requests.
2. .\lI refunds will be returned to the original pacer in the form of a check via t.S postal service.
3. Please allow 3-4 weeks for processing refund requests..
U,3 .//o Tri r/ z 4, 27 /, -lir--
FOR OFFICE USE ONLY
Route to tics Admin: Date By # Route to Records: Date ,/1s/ /9 By lir
Refund Processed: Date / /f_- Bi Invoice Processed: Date By
Permtr Canceled: Dated e. By4i0e Parcel Tag:Added: Date By
I:\ISuilding\Fon,\Iteylcrn,it.\cu,,u 9231. or
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TIGARD
City of Tigard
July 16, 2018
Clean Water Services
Administration Building Complex
2550 SW Hillsboro Highway
Hillsboro, OR 97123
Re: Permit No. SWR2017-00259
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16580 SW 85th Ave.
Project Name: Clean Water Services - O&M Phase 2
Job No.:
Refund Method: ® Check#228915 in the amount of$7,590.00.
❑ Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Permit issued for the wrong site address; should have been for 16060 SW
85th Ave for TPS building. Refund 100% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
<9?"7447-e7-- ---
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
p 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 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: Clean Water Services DATE: 6/22/2018
Administration Building Complex
2550 SW Hillsboro Highway REQUESTED BY: Dianna Howse
Hillsboro, OR 97123
TRANSACTION INFORMATION:
Receipt#: 414192 Case#: SWR2017-00259
Date: 11/30/2017 Address/Parcel: 16580 SW 85th Ave.
Pay Method: CreditCard Project Name: CWS- O&M Phase 2
EXPLANATION: Permit issued at wrong address;should have been for 16060 SW 85th Ave. for the TPS
.,. }. project;refund 100% of permit fees.
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Sewer Connection Fee 500-0000-25500 $7,590.00
TOTAL REFUND: $7,590.00
APPROVALS: SIGN RLS/DATE:
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
KV MFORVDI S S,3 0)100� TIQVUSEC?,
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Case Refund Processed: Date: 29//? By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
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Dianna Howse
^
From: Dan Garbely <GarbelyD@CleanWaterServices.org>
Sent: Friday,June 22, 2018 2:29 PM
To: Dianna Howse
Cc: #Building Permit Technicians
Subject: RE: SWR2017-00259 - 16580 SW 85th Ave.
You can mail the refund to Deb Emery at ABC.
Administration Building Complex
2550 SW Hillsboro Highway
Hillsboro OR 97123
With note:
Refund for building permit taken out in error.
TPS Building remodel: Project 6788.
From: Dianna Howse <Dianna@tigard-or.gov>
Sent: Friday,June 22, 2018 12:22 PM
To: Dan Garbely<GarbelyD@CleanWaterServices.org>
Cc:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov>
Subject:SWR2017-00259- 16580 SW 85th Ave.
Hello Dan,
As we discovered, the Western Plumbing, Inc. plumbing and sewer permits were taken out for the O&M building
address in error, and they already had permits for the TPS building where the performed the work.
I am processing a refund on both permits, plumbing fees paid by Western Plumbing and sewer SDC fees paid by
CWS. Please see the attached receipt and provide me with the mailing address information and the name of someone
to send this to.
Thanks for your help!
Dianna L. Howse
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
1
CITY OF TIGARD SEWER CONNECTION PERMIT
1 HI it . COMMUNITY DEVELOPMENT Permit#: SWR2017-00259
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/18/2018
TIGARD 13125 2S113B000600
Jurisdiction: Tigard
Site address: 16580 SW 85TH AVE
Project: Clean Water Services Subdivision: None Lot: None
Project Description: O&M Building-Phase 2- 1.38 EDU increase
Contractor: Owner: BURLINGTON NORTHERN INC
PROPERTY TAX DEPT
PO BOX 961089
FORT WORTH, TX 76161
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 11/30/2017 $7,590.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 1.38
Total $7,590.00
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 ..'. a c1py of the rules or direct questions
to OUNC by calling 503. .1987 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspectio (ate.
This permit card shall be kept in a conspicuous place on the job site until co -tio e projec
Approved plans are required on the job site at the time of each inspectio .
uAccumulative Sewer Tally
= Tenant Name: Clean Water Services SWR# 2017-00259
T 1 G A R D Site Address: 16580 SW 85th Ave PLM# 2017-00321
Parcel#: 2S113B00600
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 1 2 1
2
Drinking Fountain 1 0 0
0 0 0
Eye Wash 1 0 0
0 0 0
Floor Drain/Sink: -2 inch 2 0 0 2
4 2 4
-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 1
1 1 1
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
-Stall 0 0 0
2 0 0 1 2 1 2
Sink:
-Lav/Bar-Non-Food Related 2 0 0 2
4 2 4
-Bradley 5 0 0
0 0 0
-Com/Sery/Util-Food Related 3 0 0 1
3 1 3
Swimming Pool Filter 1 0 0
0 0 0
Washer-Clothes 6 0 0 0 0
0
Water Extractor 6 0 0
0 0 0
Water Closet-Toilet 6 0 0 1
Urinal 6 6 1 6
0 0 0 0 0
Previous EDU Count 0
0
Capped EDU Credit
TOTALS 0 0 0 0 9 22 0
9 22
Current Fixture Value 22 divided by 16= 1.375 Current EDU
1 EDU= $5,500.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 22 divided by 16= 1.375 over (under) $ 7,590.00
Enter EDU Change Here 1.380 *
*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: Per CWS,garbage disposals for employee use do not get charged SDC fees.
Authorized Name/Signature: Debbie Adamski Date: 8/9/2017
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_5500_070117.xlsx