Permit Support Document (39) Permit Application ///? 4w-
Building
Commercialill ��►� - FOR OFFICE USE o L�
Cl of Tigard Received
g DateBy. � Permit No.: r L ���--
13125 SW Hall Blvd.,Tigard,OR 97 ,(
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Plan Revi w
Phone: 503.718.2439 Fax: 503. % y. '� Other Permit:
sDateB C —i —
TIGARD Inspection Line: 503.639.4175 nit Date Ready/F3y: 9 ll Juris: 0 See Page 2 for
Internet. www.tigard-or.gov �� �v
Notified/Method'et :p'/1/i 5 Supplemental Information
1✓' -`n�/�(� /c am PP
TYPE OF WORK � �
�t1 Vw ��'� REQUIRED DA-TA:1-AND 2-FAMILY~DWELLING
❑New construction 0 RKi l 's Permit fees*are based on the value of the work performed.
• '�� ? Indicate the value(rounded to the nearest dollar)of all
El Addition/alteration/replacement ',74i,ei ; . equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
Valuation: $
❑ 1-and 2-family dwelling fil Commercial/industrial
0 Accessory building 0 Multi-family Number of bedrooms:
0 Master builder 0 Other: Number of bathrooms:
JOB SITE INFORMATIONAND LOCATION Total number of floors:
Job site address: I t,j('('). s v.), —e New dwelling area: square feet
City/State/ZIP: �Fst1i( � I • c-7;,�, Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: h, X6.4 te-;t-4\1, Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
_ if
Request for Permit Action REGFIVPD
TI Ci A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gdAN 4 2019
CITY OF TIGARD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) , d�,c iC 7 % • - / ;!`
Mailing Address: /6 2( t) Jt/J iz 5 c i/o
City/State/Zip: 7, ;,.�(/ �, ' q?.,2,1-ii
Phone No.: c-Of3J cii,- 66C y
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CA EL/.TOID PERMIT APPLICATION.
FUND RMIT FEES (attach copy of original receipt and provide explanation below).
C._❑ . INV K FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ej4f":d/'1 0.72..75"
Site Address or Parcel#: 1 6 i J (ti 2, N.i S
,1 6
Project Name: fZ4' 'r fe )4-' / /}/�'
Subdivision Name: Lot#:
EXPLANATION: /44r..v 71Z�Jr=�'' �I1/ �/'t�`c.,1". "u`f'.` e6� Jil--OL) - -
2
(-701 (- 4^-fetr ,O;',--K,YVv' L-1,0 "J y,0 av7--0D,71-"74,, ,—'iATO_C.'
772-4--Ars Fen It ertS ki4 o i22- " 7Z 6E / 'T—u' z=.
Signature: -"=' .. - ` !r " Dater y (2_(--;)9
(-__. - ---
Print
Name: '"- '\ ,r-.
-
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: 7 Date 4 By ':"7-2 Route to Records: Date e/S //� B,
Refund Processed: Date ` , /2 By +...1 Invoice Processed: Date By
Permit Canceled: Date -9 Bak''. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 518.doc
up
1111 .
TIGARD
City of Tigard
April 4,2019
Andersen Heating, Inc.
16285 SW 85th Ave., Suite 410
Tigard, OR 97224
Re:Permit No. BUP2018-00275
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 16285 SW 85th Ave, 302
Project Name: Andersen Mechanical
Job No.: N/A
Refund: ® Check#231668 in the amount of$143.15.
D Credit card "return"receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Refund overpayment of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
I:\Building\Refuncau5rWoN. eave!aNI,siiegon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
City of Tigard
r►c n R n 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: Andersen Heating, Inc. DATE: 3/28/2019
16285 SW 85th Ave, Ste 410
Tigard, OR 97224 REQUESTED BY: Dianna Howse
BT
TRANSACTION INFORMATION:
Receipt#: 421362 Case#: BUP2018-00275
Date: 2/4/2019 Address/Parcel: 16285 SW 85th Ave,302
Pay Method: CreditCard Project Name: Andersen Mechanical
EXPLANATION: Refund overpayment of permit fees.
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'�i rag r 1nb �� '"u�/.` °y4( £.‘a;r' ° 4,1'�°aq�pAka °�� ��`"�
a� NS „ tLp s � fib,
Cash Over 100-0000-48001
$143.15
TOTAL REFUND: $143.15
APPROVALS: SIGNAT RES DATE:
If under$5,000 Professional Staff .+
If under$12,500 Division Manager
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
Case Refund Processed: Date: / S /47 By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010