Permit Support Document V 0
Cit ofTigard � COMMUNITY DEVELOPMENT DEPARTMENT
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2Request for Permit Actionipl
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TIGARD 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 TigardBuildingPermits@tigard-or.gov
FROM: Owner ❑ Applicant ❑ Contractor City 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 (✓):
VCANCEL/VOID PERMIT APPLICATION.
nREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: Lf- c19 -OO 9'/
Site Address or Parcel#: /oz/JG2 L5,-:..) ,S c."-/-e i-e S P&-22.4y /2-.6.
Project Name: 0/VC- /('. 4--
Subdivision
Subdivision Name: Lot #:
EXPLANATION: $y, ,,a.r/-/ C-..� 2/2-r-' i(1,T7-1-L., A1,0 ' i-C7 J
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Signature: �, Date: /2--/VA 9
Print Name: ., j ,✓,,Eger' .7. -7T-4-k--,1-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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: Date By Route to Records: Date /jam y /9. B
Refund Processed: Date Ai/4— By Invoice Processed: Date By
Permit Canceled: Date /j/i//9' By "F"` cel Tag Added: Date By
i:\Building\Forms\RegPermitAction_12C1518.doc
V 0 1 0 /,./4-/// -
a•n Permit Application ="/ _
RFOFVPD
Commercial FOR OFFICE USE ONLY
�Y (T OCT 2 3 2019 Received
Date/By: /p /1 / I ,y��UG�._Uu�
Ci of Tigard
" 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review r
I Phone: 503.718.2439 Fax: 503.598.19�A ; l :,'„-I� f v 9 ,, f Other Permit:
DateBy: `b /
T f G A K D Inspection Line: 503.639.4175 B UI LD [ .-+ DI U s ,ON Date Ready/By: Juris: H See Page 2 for
Internet: www.tigard-or.gov Notified/Me_... , it,�' Supplemental Information
TYPE OF WORK _ REQUIRED DATA:1-AND 2-FAMILY DWELLING
❑New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
VIAddition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
El1-and 2-family dwelling KCommercial/industrial Valuation: $
❑Accessory building ❑Multi-family Number of bedrooms:
❑Master builder ❑Other: Number of bathrooms:
JOB SITE INFORMATION AND'LOCATION, Total number of floors:
Job site address: (2 t e Q 5 ,) CJG�n((S ec� New dwelling area: square feet
City/State/ZIP: 7-196 , O it Of 1-2_23 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name: 0 n e. M -,C J Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
4(7 -'4e(& !X� GO x'11 er O F J LJQ SCA oil S '-,..,t•�(�t� Other structure area: square feet
et s / •/.51A✓e-- REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: 1 Lot no.: Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: YS 13 4(3G 002-00
equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF MRK ; . .. ., work inicated on this application.
fetel aI1t i/he rolemer ► ine. ci
n i-Nei etpt›e t(.i'+1 cvi Valuation: $ ?So,oat,
tarn ergs � Sique91el Cen4Q-r Co//5ZS•4+'tg oc iion-5-frya.ral Existing building area: Lit Coo square feet
p 11,:6,05, :1"sags 1 C~Se.waNs -FT.n:St,,Pe51 A MEP 6.,04-16New building area: square feet
[] PROPERTY OWNER .. ! :TENANT': '," Number of stories: Y,
Name: 0,)e. oat,-to( 6en v Type of construction: v—tg
Address.: 1 EMbc 6\.e Co Ce.n4e.0 r Iq'`Ft•N Fl 0ev' Occupancy groups:
City/State/ZIP: 5G•'1 Ff c leuco, CA qt./it( • Existing: 1,A. _ M2d'e_.4,Af,le-
Phone:( ) Fax:( )
New: tt — 105:nQ SS
lid APPLICANT Eg CONTACT PERSON BUILDING PERMIT FEES*
t (Pkaserefer tofeeschedule)
Business name:
per,,,IT Adv'i SdeS Structural plan review fee(or deposit):
Contact name: p t h ek t'6,_ 12..20
FLS plan review fee(if applicable):
Address: s w d 611: e 6 i'a. -'
City/State/ZIP: ( fl►Q�i 1 Total fees due upon application:
,test 1 1-141 s 1 ea
Phone:(g[g )6d2"3b1.o Fax: :( ) Amountreceived:
i; n
r Stems •• GOAL PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES*
E-mail: r;C- krY� e e t„,.,+
CONTRACTOR Commercial and residential prescriptive installation of
roof-top mounted Photo Voltaic Solar Panel System.
Business name: fi-t;10 Tim,En100 1.4,, a) Jc rm..,cT7o,✓ 'NSpbmit two(2)sets of roof plan with connection details
d fire department access,along with the 2010 Oregon
Address: /G Sq ,4 ,:fid r/e u• Solar Installation Specialty Code checklist.
City/State/ZIP: Permit fee(includes plan review
A e g/7ef 6 _ and administrative fees): $180.00
Phone:F709 4 yq —Q3 iv Fax:( ) State surcharge(12%of permit fee): $21.60
04 CCB lie.: /,f /7L� Total fee due upon application: $201.60
Authorized signature: /91.„.„-1This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: 2;G{.t or-& (LD Date: t 0/2.-skq * Fee methodology set by Tri-County Building Industry
Service Board.
I:\Building\Permits\BUP-COM PermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
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