Permit (4) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
i g ` Request for Permit Action
T I C A R h) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 50 7 4 jTard-or.gov
TO: CITY OF TIGARD JUN 2 9 2020
Building Division CITY OF TIGARD
13125 SW Hall Blvd.,Tigard, OR 97223 BUILDING DIVISION
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingFermits@tigard-or.gov
FROM: X Owner/eft AT El Applicant El Contractor ❑ City Staff
Check(V)one /
6FUND))R Name:
INVOICE TO: (Business or Individual) 4,44 A n4k Ttt Pd- soci ,f 7
Mailing Address: id SZIo SL wu•s1-z,,I L Siftt 'i S .24-� A-103 _
City/State/Zip: far-
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Phone No.: c/d Aal. 1.474K, C,Fe S'o)-•-02-Li 37 3
606• lore c c,:t -Cati,
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
D PERMIT APPLICATION.
REFUND PE IT FEES (attach copy of original receipt and provide explanation below).
OR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: P L/V1202.0 -00 0..-1 / CS///Z-2O.20 —OOO...7 , _h
Site Address or Parcel#: l0(by StA.J We 1iA 1 fa„ Sport R t1 . U,,,:+ B-3
Project Name:
Subdivision Name: — Lot#: —
EXPLANATION: 'at i r,5;.ri p i..,,,II,:Ai t,...,,,,`�F urea oj+ati►rdt,GA. a.,r L ',,L_�1Gsc ah f Ii4 v_ (Jco•t k
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Signature: 1` r C.r a Date: G•LS-Zo
Print Name: iolizr1- /-474n C.Fc) N'TPS
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Admin: _ Date j By J.p Route to Records: Date 9 er By -,/1'
Refund Processed: Date ' Lj By JO Invoice Processed: Date By
Permit Canceled: Date ,./ ,9.- B A"e Parcel Tag Added: _ Date By
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TIGARD
City of Tigard
February 11, 2021
Hannah The Pet Society
10526 SE Washington St, Suite A103
Portland, OR 97216
Re:Permit No. PLM2020-00027 SWR2020-00036 J
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: 10164 SW Washington Square Rd
Project Name: Hannah The Pet Society
Job No.: N/A
Refund: ® Check#238213 in the amount of$738.03.
❑ Credit card "return"receipt in the amount of$ .
❑ Trust account"deposit" receipt in the amount of$ .
Notes: Revised scope of work resulted in an overpayment of$42.03 on PLM2020-00027
and$696.00 on SWR2020-00036, for total refund of$738.03.
If you have any questions please contact me at 503.718.2430.
Sincerely, a_l____— 1
Dianna /(�/
Howse
Building Division Services Coordinator
Enc.
g 11 125 SW uull1B�gde !']�oRiapregon 97223 • 503.639.4171
L\Buildin \Refunds\?12stration\2 fr e
TTY Relay:516�.684.2772 • www.tigard-or.gov
111111
City of Tigard
3.i G s1 RDj 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
i 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: Hannah The Pet Society DATE: 2/8/2021
10526 SE Washington St,A-103
Portland, OR 97216 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 427811,427812 Case #: SWR2020-00036,PLM2020-
00027
Date: 1/21/2020 Address/Parcel: 10164 SW Washington Sq Rd
Pay Method: CreditCard Project Name: Hannah Pet Society
EXPLANATION: Per applicant's request as change in scope of work resulted in overpayment and sanitary
sewer SDCs. Refund overpayment in full.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Cash Over 100-0000-48001 $696.00
Cash Over 100-0000-48001 42.03
1
TOTAL REFUND: $738.03
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff ,, `
If under$12,500 Division Manager D. L. Or t.elcvb
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: V12, By: a
I:ABuilding\Refunds\RefundReauest.doc x 09/01/2010
iogCITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T T G A x.lD
Project Name: Hannah Pet Society
Site Address: 10164 SW WASHINGTON SQUARE RD
`emu-%•o6
Receipt Number: 436272 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2020-00036 $-696.00
Total: $-696.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 238213 DHOWSE 09/04/2021 $-696.00
Payor: Hannah the Pet Society
Total Payments: $-696.00
Balance Due: $696.00
_..._ ... . .. . . .. .. . . N.
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Tft_;AI l.?
Project Name: Hannah Pet Society
Site Address: 10164 SW WASHINGTON SQUARE RD
Receipt Number: 427811 - 01/21/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2020-00036 Sewer Connection Fee 500-0000-25500 $754.00
SWR2020-00036 Cash Over 100-0000-48001 $696.00 4,
Total: $1,450.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5966902 PUBLICUSERO 01/21/2020 $1,450.00
Payor:
Total Payments: $1,450.00
Balance Due: $0.00
Fw: PLM2020-00027 SWR2020-0003 , Hannah -
� Pet Society 10164
SW Washington Square c
Bob Logan
Thu 6/25/2020 2:06 PM
Sent Items
To:TigardBuildingPemits@tigard-orgov <TigardBuildingPemits@tigard-orgov>;
Cc:Vernie Santos <vernie@flagassistgolfcom>; kodiakplumbing@comcast.net <kodiakplumbing@comcast.net>;Chrys Barklow
<Chrys.Barklow@hannahsociety.com>;
2 attachments (805 KB)
SKM_C65920062315540.pdf; permit application refund request.pdf;
Dear City of Tigard Building Department,
Please find attached a Request for Refund related to permit#: PLM2020-00027, along with supporting
documentation.
Please call or write if you have any questions or need additional information.
Thank you for your assistance,
Bob Logan, CFO
Hannah The Pet Society
mobile: S03.502.4373
From: robert logan <robert.l@arsrig.com>
Sent:Thursday,June 25, 2020 1:08 PM
To: Bob Logan
Subject: Fwd: PLM2020-00027 &SWR2020-00036- Hannah Pet Society- 10164 SW Washington Square Rd
Sent from my iPhone
Begin forwarded message:
From: Vernie Santos <vernie@flagassistgolf.com>
Date:June 24, 2020 at 6:07:39 AM PDT
To: robert logan <robert.l@arsrig.com>
Subject: Fwd: PLM2020-00027&SWR2020-00036- Hannah Pet Society- 10164 SW Washington
Square Rd
Here is paper work from City of Tigard with a Refund Request form please fill out form and they will
return $738.03 to you for overpayment of original permit fees.
Vernie Santos
Begin forwarded message:
From: Gail Santos<kodiakplumbing@comcast.net>
Subject: Fwd: PLM2020-00027 & SWR2020-00036 - Hannah Pet Society- 10164 SW
Washington Square Rd
Date:June 23, 2020 at 6:40:10 PM PDT
To: vernie.s@arsrig.com
CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT p/w Permit#: SWR2020-00036
T r G AR D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/21/2020
Parcel: 1 S 135BA00102
Jurisdiction: Tigard
Site address: 10164 SW WASHINGTON SQUARE RD
Project: Hannah Pet Society Subdivision: OAKBURG
Lot: 9
Project Description: 6/23/2020: REPRINT permit to correct EDU increase to.13
Contractor: Owner: PPR SQUARE TOO LLC
PO BOX 847
CARLSBAD, CA 92018
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee
01/21/2020 $754.00
Type of Use: COM Cash Over 01/21/2020 $696.00
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .13
Total $1,450.00
Required Items and Reports(Conditions)
-us permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
w. 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
Drk is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
enter. 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
OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: / 60� Permiftee Signature:
e/Y4',' /C_J7-77-70A9
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.
r11 1 L 7
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
w- 503.639.4171
Project Name: Hannah Pet Society
Site Address: 10164 SW WASHINGTON SQUARE RD OPG1 Ai 4-L-
Receipt Number: 427811 - 01/21/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER FAIR
SWR2020-00036 Sewer Connection Fee 500-0000-25500 $1,450.00
Total: $1,450.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5966902 PUBLICUSERO 01121/2020 $1,450.00
1 Payor:
Total Payments: $1,450.00
Balance Due: $0.00
I
v.
Accumulative Sewer Tally
Tenant Name:HANNAH PET SOCIETY SWR# 2020-00036 REVISED
)1s.,,A1;t)
Site Address: 10164 SW WASHINGTON SQUARE RD PLM# 2020-00027
Parcel#: 1 S135BA00102
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptisers/Font 4 _ 0 0 0 0_ 0
Bath: -Tub/Shower 4 0 0 0 1 4 1 4
-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 0 0 0
Drinking Fountain 1 0 0 0 0 0
Ee 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
(b:trl).tgt 1)i:,,p(1<;ll;
-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 9 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
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 0 _ 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 1 a 2 1 2 0 0
-Bradlee 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
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 0 0 0
Urinal 6 0 1 6 0 -1 -6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 2 8 4 10 2 2
Current Fixture Value 2 divided by 16= 0.125 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 2 divided by 16= 0.125 over (under) $ 754.00
Enter EDU Change Here 0.130 *
*Round EDUs to the nearest 1/100th: a count endin: in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: Dianna Ornelas Date: 6/23/2020
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.
1•\Flit vile-lino\Swayi,Tally\SewerTallvSheet SR00 070119.xlss
CITY OF TIGARD SEWER CONNECTION PERMIT
1111
COMMUNITY DEVELOPMENT Permit#: SWR2020-00036
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/21/2020
Parcel: 1 S 135BA00102
Jurisdiction: Tigard
Site address: 10164 SW WASHINGTON SQUARE RD
Project: Hannah Pet Society Subdivision: OAKBURG Lot: 9
Project Description: .25 EDU increase.
Contractor: Owner: PPR SQUARE TOO LLC
PO BOX 847
CARLSBAD, CA 92018
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 01/21/2020 $1,450.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .25
Total $1,450.00
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty and all other applicable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started with • ,0 days of issuance, or if
work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopte.. by' "*/Oregon Utility Notification
Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a c•py, • - rules or direct questions
to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
Call . 39.4175 by 7:00 a.m.for the next available inspection d.,.
This permit card shall be kept in a conspicuous place on the job site until compl/io of e project.
Approved plans are required on the job site at the time of each inspection.
III Accumulative Sewer Tally
Tenant Name: HANNAH PET SOCIETY SWR# 2020-00036
c `i`i Site Address: 10164 SW WASHINGTON SQUARE RD PLM# 2020-00027
il , Parcel#: 1 S 135BA00102
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 0 0 0
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
-3 inch 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 0 0 0
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 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 4 2 4
Current Fixture Value 4 divided by 16= 0.250 Current EDU 1 EDU= $5,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 4 divided by 16= 0.250 over (under) $ 1,450.00
Enter EDU Change Here 0.250 *
*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:
Authorized Name/Signature: BRANDEN TAGGART X2449 Date: 1/21/2020
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_5800_070119.xlsx