Permit Support Document (35) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
1
11111111 Request for Permit Action ./x/6/4-'
T I 6, R 11 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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TO: CITY OF TIGARD RRRRRR OCT 1 1 2 18
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
1 @Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingernitstigardior:gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor VThity Staff
Check(✓)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. 'f0 S'
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is REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). •/ I` „l
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ,GSC G
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: �L,/k 0?0/ I- - t,0 e 7 _Y
Site Address or Parcel#: 1 70 ' 7 SLaj A-rl/,ple-r /�
Project Name: / ' �' S j • L< � .,
Subdivision Name: Lot #:
EXPLANATION: ( /hz-4 c/ f - A.0fit- Up V 7 5) 7 f
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Signature: /0/" (' '--
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Print Name: L'"/(' r- r,if)4 kw ,-it
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /,7 A B afa Route to Records: Date /.:,;Art, B ._
,i Processed: Date /j/ /jyf B ifu.i Invoice Processed: Date By
Permit Canceled: Date / ti, , By . r arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 2314 oc
CITY OF TIGARD PLUMBING PERMIT
1 COMMUNITY DEVELOPMENT Permit#: PLM2018-00475
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/11/2018
T r A r C� Parcel: 2S1060001400
Jurisdiction: Tigard
Site address: 17077 SW APPLEDALE RD
Project: River Terrace East Apartments,Building B Subdivision: RIVER TERRACE EAST Lot: None
Project Description: Building B: New 22 unit apartment building. Backflow preventer for landscape irrigation.
Contractor: ANDERSEN HEATING, INC. Owner: POLYGON WLH, LLC
16285 SW 85TH AVE STE 410 703 BROADWAY ST, SUITE 510
TIGARD, OR 97224 VANCOUVER,WA 98660
PHONE: 360-695-7700
HONE: 503-992-6664
FAX: 503-536-6615
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 10/11/2018 $31.27
Specifics: 1 12%State Surcharge- 10/11/2018 $8.70
Plumbing
Type of Use: MF 41 ea Minimum Fee Adjustment- 10/11/2018 $41.23
Class of Work: OTR Plumbing
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 obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: //et
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`i Permittee Signature: Sr—r ., `(vG;
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.
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Plumbing Permit Applic ; CE ..
Building Fixtures FOR OFFICE USE ONLY
City of Tigard t- 2018 Received G ii / /� Pem 4/ ,6` / -t/e+
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7 fiGARanRevA 4 Date/B�so ` ' tction Line: 503.639.4
TIGARD i �(y�t DateReady/By: Sark: See Page 2 for
Internet:wm�vvtigard-or.go 1d Pl��p I r �i .Notified/Method: supplemental Information
R:t:..�� _ �yE D1--i e�R e 4 '�i.A.,v= .4. =,:ra" . r,aKI- SSE*S �D I'`.., i
New constructionFor special information rise checklist
® 0Demolition P l �
Description I Qty. I Ea I Total _
❑Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 R.for each utility connection)
..-r- -�.�cc '- e. - - SFR(I)bath
_ ....W t A'' 00�C.QU - ... - 372.70
•
1-and 2-family dwelling 0 Commercial/industrial SFR(2)bath 437.78
❑Accessory building Multi-family SFR(3)bath 500.32
Each additional bath/kitchen 25.02
D Master builder 0 Other
_ _ Fire sprinkler(-sq.ft) Page 2
UB SI =MT O „Ol 0 i - _-f Site utilities:
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General Ledger
Journal Entry Proof List :III amyl ot
Printed: 11/20/2018- 5:14 PM
Batch: 10007.11.2018
TIGARD
Account Number Account Description Debit Amount Credit Amount Line Description
Project Management
Journal Entry:312-05-2019 Journal Entry Date:11/20/2018
100-0000-24001 State Building Permit Surcharg 8.70 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00476
100-0000-22000 Customer Deposits 0.00 72.50 Correct Polygon Permit Duplicates-Case PLM2018-00476
100-0000-22000 Customer Deposits 0.00 8.70 Correct Polygon Permit Duplicates-Case PLM2018-00476
100-0000-24001 State Building Permit Surcharg 8.70 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00475
100-0000-22000 Customer Deposits 0.00 72.50 Correct Polygon Permit Duplicates-Case PLM2018-00475
100-0000-22000 Customer Deposits 0.00 8.70 Correct Polygon Permit Duplicates-Case PLM2018-00475
100-0000-10100 Cash 145.00 0.00 Fund balance entry for fund 100
230-0000-43101 Plumbing Permits 72.50 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00476
230-0000-43101 Plumbing Permits 72.50 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00475
230-0000-10100 Cash 0.00 145.00 Fund balance entry for fund 230
Journal Entry Totals 307.40 307.40
Journal Entry Balance 0.00
Report Totals: 307.40
307.40
0.00
GL-Journal Entry Proof List(11/20/2018- 5:14 PM)
Page 1
a CITY OF TIGARD
13125 SW Hall Blvd.,Tigard OR 97223
TIGARD 503-718-2439
TRUST ACCOUNT DEPOSIT RECEIPT
Receipt No.: 420554 Date: 12/3/2018
TRUST ACCOUNT ID ACCOUNT CODE AMOUNT
2016-00002 100-0000-22000 $81.20
PAYMENT METHOD CHECK# CASHIER ID
Journal Entry JE 312-05-2019 D HOWSE
PAYOR: Polygon WLH, LLC
COMMENTS: Deposit to trust account.
CITY OF TIGARDIliII RECEIPT
a • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
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Project Name: River Terrace East Apartments, Building B
Site Address: 17077 SW APPLEDALE RD
Receipt Number: 419901 - 10/11/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2018-00475 Backflow Preventer 230-0000-43101 $31.27
PLM2018-00475 12%State Surcharge-Plumbing 100-0000-24001 $8.70
PLM2018-00475 Minimum Fee Adjustment-Plumbing 230-0000-43101 $41.23
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Trust Account 2016-00002 JDRINKWATER 10/11/2018 $81.20
Payor: Polygon WLH, LLC
Total Payments: $81.20
Balance Due: $0.00
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