Permit Support Document (19) ' ,- it- Request
of Tigard • CO,\ih9UNITY DEVELOPMENT DEPARTMENT b � wp i"
it
o
quest for Permit Actio o . J ;>�,;,
1.I >i Ria 13l?5 SW Hall Blyd. •Tigard, Oregon 97223 • 503-
i .� 503-718-2439 • r't+n;'.t`' ;nor .'
.tit..
• TO: CITY OF TIGARD ,
.�' Building Division
w
13125 SW Hall Blvd.,Tigard,OR 97
223 N.
Phone: 503-718-2439 lax: 503-59g 1961) /l /��
FROM: 7�gardl3uildin Pe
0Owner $ rnuts rr Tigard orgo�.
Check(✓)one 0 Applicant
Contractor 0 City Staff
REFUND OR Name:
INVOICE TO: (Business or Individual) / //
Mailing Address: 7/3 i
0'10,1--le , ,� S
City/State/Zip: Q a
Phone No.: _/
°3 '71 (/d3 7
PLEASE TAKE A'N'ION FOR THE ITEM(S)CHECKED1 :
CANCEL/VOID PERMIT { )�
APPLICATION.
REFUND PERMIT FEES(attach copy of original receipt and r
❑ INVOICE FOR FEES DUE provide explanation below).
❑ REMOVE/REPLACE (attach case fee schedule and provide explanation below).
VE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#
•
A-2-
Site Address or Parcel #: t-2 a A ,
Subdivision Name:
EXPLANATION: Lot#:
Signature:
Print Name: If .1" Date: 0I'G4ta.r At-2/moo /a_
IlthasLiPalicx
1.
The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any Re which was erroneously paid or collected.
• Nor more than 80"/u of the a
No been exhanded application or plan review fee when an application is withdrawn or canceled before review effort
ha2. All refu•
n of more
be returned than 80%of
to the application or permit fee for issued
3. Aerie allow 3. original payer in the form of a checkviaUS poor s any inspection requests.
4 weeks for processing refund requests. Postal service.
So 1. i6
3 7. /,L_.
Route toS.sAdmin: 1'OR OI'I'ICI' t l: i? IN
resri
Refund Pr Date B ecor
Processed: Date y Route to Rees; Date �1
n,.,„.:.1'..........1.-1-
/2/0 •�� B s�-•r' Invoice Processed: ® � B' -
/7 .. Date,
un
p
TIGARD
November 20, 2017 City of Tigard
Assured Electric LLC
7138 Marley Lane S
Salem, OR 97306
Re: Permit No. ELC2017-00719
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15974 SW 76th Ave.
Project Name: HSU
Job No.: N/A
Refund Method: ® Check#226723 in the amount of$346.37.
❑ Credit card"return"receipt in the amount of$
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): Work was performed under master permit for new single-family
residencie. 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
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: Assured Electric LLC DATE: 11/8/2017
7138 Marley Lane S
Salem, OR 97306 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 413067 Case#: ELC2017-00719
Date: 9/28/2017 Address/Parcel: 15974 SW 76th Ave.
Pay Method: CreditCard Project Name: HSU
EXPLANATION: Work was performed under master permit for new single-family. Refund 100%of
permit fees.
AM++ p A
rr� �
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„,S3 ,e w4L ,47,F3.
p-e 40447; 1\ Ea' trOlaiiiigt; (a
a.10 .;.44.,M21:1;14-:"*
Y �
f s „
•
Electrical Permit 220-0000-43103 $309.26
12%State Surchar•e• 100-0000-24001 37.11
TOTAL REFUND: $346.37
APPROVALS: SIGNATU S 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
F:04 TTDEI SYST E All
1•tiMUTIQNVSE.ONLY
Case Refund Processed: Date:
0e. I By: I
IABuilding\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD
II I 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
Tr Cl Al2T.)
Project Name: New Construction
Site Address: 15974 SW 76TH AVE
IReceipt Number: 416576 - 04/06/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00719
$-346.37
Total: $-346.37
PAYMENT METHOD CHECK# CC AUTH.CODE
Check ACCT ID
CASHIER ID RECEIPT DATE RECEIPT AMT
226723
DHOWSE
Payor: Assured Electric LLC 04/06/2018 $-346.37
Total Payments: $-346.37
Balance Due: $346.37
Page 1 of 1
IAI CITY OF TIGARD
13125 SW Hall Blvd.,Tigard OR 9722 RECEIPT
503.639.4171 3
TIGAR 1)
Project Name: New Construction
Site Address: 15974 SW 76TH AVE
® 6-(/✓n7___
Receipt Number: 413067 - 09/28/2017
CASE NO. FEE DESCRIPTION
ELC2017-00719 REVENUE ACCOUNT NUMBER PAID
Services or Feeders-200 amps or less
70
ELC2017-00719 Branch Circuits w/Purchase Service or 220-0000-43103 $1
Feeder 220-0000-43103 $133.560.
ELC2017-00719 Signal circuit or Limited Energy Panel
ELC2017-00719 12%State Surcharge-Electrical 220-0000-431037.11
100-0000-2244103 001 $337.1111
5.
Total: $346.37
PAYMENT METHOD CHECK# CC AUTH.CODE
Credit Card ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Payor: Michael Zima 00444G PUBLICUSER141 09/28/2017
$346.37
Total Payments: $346.37
Balance Due: $0.00
Page 1 of 1
I
Electrical Permit Application
FOR Conten.usr osIN
illCity of Tigard Received'
13125 SW Hall Blvd.,Tigard,OR 4729
j Plate/li: Permit �/
t t: Phone: 5017182439 Fax: $03,598.1 E I VE'- Plan Review '
Inspection Line: 503.639.4175 ry Dete18 ' Related Permit#:
T l C;A R D Internet: Line:gard-or.gov �" O 11 Ready Date BY: Jerk:Read DM/By: Si See Page 2 for
Supplemental information
TYPE OF WO
❑New eonsrnlction [�Addirinnlahc t�q �I �r!et�(�, PLAN REVIEW
6J i.lil_:�+ I.!/VISION Please check all that apply(submit a sets of plans w/items checked):
LIScrvicc or feeder 400 amps or more 0 Building over three Stories.
❑Demolition 0 Other:
CATEGORY OF CONSTRUCTION where the available fault current 13 Marinas and boatyards.
CI 1-and 2-fame! dwelln ° ° exceeds 10,000 amps at 150 volts or 13 Floating buildings.
Y g ❑Commercial/industrial 0 Accessory buildin less to ground,or exceeds 14.000
❑Multi-family S OC:ommercial-usragricuhural
❑Master builder 0 Otheramps for all other installations, buildings.
JOB SITE INFORMATION AND LOCATION ❑Fire pump. ❑installation of 150 KVA or
4 4,r r�g-; 0 Emergency system.
Job lY: Job site eddresS: G� largerstseparately derived
,{ lAdditioo ofncw motor Ipad of system.
City/State/ZIP: ? fivtoonrorrrwrc: [I A �E» 1_z�°i_3„
13 Six or more residential units, occupancy.
Suite/bldg./apt.#: I ProJeCt name: ❑Health-care facilities. 0 Recreational vehicle parks.
❑'Hazardous locations, 0 Supply voltage for more than
Cross street/directions to job site: 0 Service or feeder 600 amps or more. 600 volts nominal.
FEE SCHEDULE
[kseri,rtan
I . Fedi Total. •
Subdivision: New residential single-or multi-family dwelling unit.
I Lot#: Includes attached garage.
Tax map/parcel#: 1,000 sq.ft.or leas 168.54 4
DESCRIPTION OF WORK Ea.add'I 500 sq.ft.or portion 33.92 1
Limited energy,resideattiel
(with above sq.R.) 75.00 2
Limited energy,multi-family
residential(with above sq.ft.) 75.00 2
Renewable Ene
0 PROPERTY OWNER 0 TENANT t : -�, t7 y ❑ See
' M'. yPage 2
Name: Semites or feeders installation alteration,and/or relocation
200 amps or less 100.70 2
Address: , .400;...
133.56 2
City/State/ZIP: s r,ampss _80.34 2
Phone:( ) l
t Irr amiss301.04 2
I Fax:( ) Over 1,000 amps or volts 552.26 2
Email: Temporary services or feeders Installation,alteration,and/or
Owner Installation:This installation is beingmade on relocation
property that I own which is not 200 amps or less 59.36 I I
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701.
201 amps to 400 amps 121.08 2
Owner signature: Date: 401 amps to 599 amps 16834
❑ APPLICANT ❑ CONTACT PERISO'rit; Branch circuits—new,alteration,or extension,per panel 2
Business name: A Fee for branch ciaetiifs with
above service or feeder fee,
Contact name: each branch circuit 7,42 2
El.Fee for branch circuits without
Address: service or feeder fee,first
branch circuit 56,18 2
City/State/ZIP: Foch add'1 hranch circuit
7.42 2
Phone:( ) I Fax::( ) Miscellaneous(service or feeder not included)
Each manufactured or modular
Email: dwelling,service and/or feeder 67.84 2
CONTRACTOR Reconnect only 67.84 2
/1 l �1 r �. l Pump or irrigation circle 67.$4
Business name: A ivr T �G72
l k j L L t:.' Sign or outline lighting 67.84 2
Signal
deceit(*)or limited-energy
OlowSaebelePage 2
ZAddress 7/ 3gf, Q`�/� L�Nt $ , m,Cliy/S1aL 'Zl': �F r r` lhIadttcra
ditdroualoer ann overaln anoftheshe veq17 3 Additional inspection(1 hrm66.25/ r)Phone ( 3) C
7/ Y-,s 3 7 I Fax:( )
Investigation(1 hr min) 90.00/hr
Email: /�� may' • e� ("IC
i1 ��,,r druceria�l lanl(l hr min) 78.18/hr
1 may] \j 4 nspectiotss for which no fee is
CCB Lie.;ii6'20/ f Electrical Lic.; Ca95' I Suprv.Lie. 5'/3 S - ificallylisteddc/x hr min) 90.00/hr
Suprv.Electrician signature,requued:
KLECTRICALPERMIT FEES
Print name: /C�tA B Subtotal:
/ /!}►a—_ I a : /0 1.3 f O Plan Review Requiter!(25%of permit fee):
State surcharge(12%of ptxntit fee):
Authorized signature: TOTAL PERMIT FEE:
I Print name: I This Penni'
expires I1 a permit is not obtained witlda I80
Date: days after it has been accepted as coarpkta.