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Permit (2)
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for PermitA q ction TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • vvww.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 ❑ Contractors ty Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) „XE Al A / Vie- 2_., # � y Mailing Address: 95'/2 fez 24 oS c - 7-- City/State/Zip: 77 6 26 0/2. 17ac?- Phone No.: So 2 - , i1 j - ® 7(, PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): VOID PERMIT APPLICATION. REFUND RMIT FEES (attach copy of original receipt and provide explanation below). E FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: /is j dip-2 o QOO,..5 -, Site Address or Parcel #: ?S'y® Se') 6.L/z_©S cc— S 7— Project Name: (-619 77 Subdivision Name: Lot#: EXPLANATION: /67 mot L eie-,4?,e9 y/l1 ----,t/— 47 ,9— /LDS*-r L i 0.--/= /i CrE', 17 .L iK 4--7-7 e,✓ , Signature: .02_: -yam Date: 427/ 2,0 Print Name: .,,j j19 /,',_4- /` Z.(9.4 € 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 Gj 3 71 154/0 Refund Processed: Date .�. 'Z0 By.a Invoice Processed: Date / By Permit Canceled: Date �,./9'" By r Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_120 18.doc IIIq TIGARD City of Tigard April 3,2020 Jennifer Adamy 9540 SW Elrose St Tigard, OR 97224 Re: Permit No. MST2020-00056 Dear Applicant: The City of Tigard has processed a refund for fees on the above referenced permit(s) as follows: Site Address: 9540 SW Elrose St Project Name: Adamy Job No.: N/A Refund: ® Check#235087 in the amount of$300.44. ❑ Credit card"return"receipt in the amount of$ . 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$ . Comments: Scope of work was reduced resuling in a reduction of permit fees. Refund difference. If you have any questions please contact me at 503.718.2430. Sincerely, ,e, e4,,pi.e..e.d Dianna Ornelas Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov lig ' City of Tigard T 1 G A R D 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: Jennifer Adamy DATE: 3/20/2020 9540 SW Elrose St Tigard, OR 97224 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 428173 Case#: MST2020-00056 Date: 2/11/2020 Address/Parcel: 9540 SW Elrose St Pay Method: CreditCard Project Name: Bann- /9;64/''7 y EXPLANATION: Scope of work was reduced resulting in a reduction of permit fees. Refund overpayment. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Cash Over 100-0000-48001 $300.44 TOTAL REFUND: $300.44 APPROVALS: SIGNATURES/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 FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: /73"/ By: 47 d I:\Building\Refunds\RefundRequest.doc x 09/01/2010 q 14 CITY OF TIGARD RECEIPT I 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T I G A R L) Project Name: ADAMY Site Address: 9540 SW ELROSE ST A/L Receipt Number: 436217 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MS12020-00056 $-300.44 Total: $-300.44 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 235087 DHOWSE 09/03/2021 $-300.44 Payor: Jennifer Adamy Total Payments: $-300.44 Balance Due: $300.44 Page 1 of 1 CITY OF TIGARDII RECEIPT s 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGAI--1hi Project Name: ADAMY Site Address: 9540 SW ELROSE ST i9-fa jGCS / 6_1_> Receipt Number: 428173 - 02/11/2020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2020-00056 DC Provision Review, SF-Ping 100-0000-43112 $102.00 MST2020-00056 Building Permit-Additions,Alterations, 230-0000-43104 $119.33 Demolition MST2020-00056 Plan Review 230-0000-43106 $77.56 MST2020-00056 Info Process/Archiving-Sm$0.50 (up to 230-0000-43135 $7.50 11x17) MST2020-00056 12% State Surcharge-Building 100-0000-24001 $14.32 MST2020-00056 Tig-Tual School CET- Residential 230-0000-24102 $24.30 MST2020-00056 Cash Over 100-0000-48001 $300.44 - Total: $645.45 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 645.45 JDRINKWATER 02/11/2020 $645.45 Payor: Jennifer Adamy Total Payments: $645.45 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD1114 RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TI G A R..T_ Project Name: ADAMY Site Address: 9540 SW ELROSE ST 0,2/GiAM-L.— Receipt Number: 428173 - 02/11/2020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MST2020-00056 Plan Review 230-0000-43106 $645.45 Total: $645.45 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 645.45 JDRINKWATER 02/11/2020 $645.45 Payor: Jennifer Adamy Total Payments: $645.45 Balance Due: $0.00 Page 1 of 1 • ,1 CITY OF TIGARD MASTER PERMIT g' COMMUNITY DEVELOPMENT Permit#: MST2020-00056 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/19/2020 TIGARD Parcel: 2S111BA11300 Jurisdiction: Tigard Site address: 9540 SW ELROSE ST Subdivision: LAUTT'S TERRACE Lot: 7 Project: ADAMY Project Description: Kitchen remodel to include 18 square foot addition. ALL TRADE PERMITS TO BE PULLED SEPARATELY. BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 18 sf Basement: 0 sf Left: 5 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 5 Detectors: Total: 18 sf Value: $2,204.28 Rear: 15 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: 0 Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Drywell-Trench Drain: 0 Other Fixtures: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add!500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ALT SF VB R-3 18 Owner: Contractor: ADAMY,NICHOLAS E& SILVER TREE BUILDERS NORTHWEST INC Required Items and Reports(Conditions) JENNIFER K PO BOX 771 9540 SW ELROSE ST SHERWOOD,OR 97140 TIGARD,OR 97223 PHONE: 503-849-0166 PHONE: 503-929-6650 FAX: Total Fees: $645.45 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 ' sua ce, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notifi }, . `t... ter. Those rules are set forth In OAR 952-001-0010 through OAR 952-001-r.90. You may obtain a copy of the rules or direct questions to OUNC by call) .1 � 7 or 1.800.332.2344. _ 1 ,ix - 2 Issued By: : -� Permittee Signature: 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. Building Permit Application Residential RECEIVE For. t)F1 1( 1: I 'I..ONLY City of Tigard Received QrA //I'� , I 111 ■ 13125 SW Hall Blvd.,Tigard,OR 97223 FEB 1 1 2020 Da"/B •• : • .-- Plan Review T mit I Phone: 503.718.2439 Fax: 503.598.1960 Dawn _ Ar�0l� I i Other Per : TIGARD Inspection Line: 503.639.4175 CITY OF TIGAFiU Date Ready/Sy: ® gee Paget for Internet: www.tigardor.gov BUILDING DIVISIO Notified/Method: "1. .A' . IFESupplemental Information L 11 -t C.F7) ✓'-6:7v;n//`—Z-7"` TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING ❑New construction 0 Demolition Permit fees*are based on the value of the work performed. ddition/alteration replacerrlent 0 Other: Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. { e1-and 2-familydwellingValuation: $ +4l 9(L(t 0 Commercial/industrial r ❑AccessorybuildingNumber of bedrooms: 1 0 Multi-family M ❑Master builder ❑Other: Number of bathrooms: f�� y JOB SITE INFORMATION AND LOCATION Total number of floors: (�,� Job site address: 95 L{O 5 l,J E l Y os e. 5I r. New dwelling area: t g sq e feet City/State/ZIP: Ti5 a lie d 1 0g- 9 / Z 2.-Li Garage/carport area: square feet Suite/bldg./apt.no.: Project name: Covered porch area: square feet Cross street/directions to job site: 17-tan � Deck area: square feet Other structure area: square feet _ REQUIRED DATA:COMMERCIAL-USE CHECKLIST Subdivision: u..4'S I - ,Y Y a.. C Lot no.: 7 Permit fees*are based on the value of the work performed. Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the DESCRIPTION OF WORK work indicated on this application. K-=t4- 14..tn g�wt.od�l - Rdd 10-te% - t�..Da Ll Valuation: $ S tt (50..4 l A)tl...7 Cabl nL45 Existing building area: square feet - �.Q__ p r `rvk, - o 4JL- ?V l I �l`�'�17 New building area: square feet (it PROPERTY WNER 0 TEN Number of stories: Name: o � N l LY/ -�l to ri l�(i✓ d Q,r{q y Type of construction: Address: ell 5,40 5 W E l Iro SG S f'. Occupancy groups: �/ upon Y g• P City/State/ZIP: —grtt}ci GLv ( l _ 04 C` 7 Z Z7 Existing: Phone:(' D3) CJ l/ '1 0 T ID(0 Fax:( ) U/ 1.4 New: IST APPLICANT 0 CONTACT PERSON BUILDING PERMIT FEES* Business name: (Please refer to fee schedule) Contact name: 7 ; C el 4 G`u vk Structural plan review fee(or deposit): ~n f f FLS plan review fee(if applicable): Address: q s ti O 5 W E I,rose- 5-E-'• Total fees due upon application: City/State/ZIP: T-u, O-v 1 O g_ ci? L Phone:(03) ?II R.. 07 69( Fax::( ) N j Amount received: E-mail: j a.ci a. m y n rue; 1 . `�� PHOTOVOLTAIC SOLAR PANEL SYSTEM FEES ev,vt . J CONTRACTOR Commercial and residential prescriptive installation of _ roof-top mounted PhotoVoltaic Solar Panel System. Business name: S 11 V,L/ I v•Ge �6 u 11c1 t v.S 'lik) TN-. Submit two(2)sets of roof plan with connection details �/� I and fire department access,along with the 2010 Oregon Address:jQ ,O)C / !7 ) Solar Installation Specialty Code checklist. City/State/AP: '_ e C� 'L 0 Permit Fee(includes plan review SY\�VWDOd O i�lTlJ and administrative fees): $180.00 Phone:(5-O2j 9 Zq -10(050 . Fax:( ) AVA State surcharge(12%of permit fee): $21.60 CCB lie.: (8 05�,L� Total fee due upon application: $201.60 Authorized signature:, 1 This permit application expires if a permit is not obtained within/] � within 180 days after it has been accepted as complete. Print name: J2 H n;�'Ci10 Ad a ;It y Date:L/li 12 U L(� "Fee methodology set by Tri County Building Industry f r1i l Service Board. I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/O2/COM/WEB) j City of Tigard III ■ v COMMUNITY DEVELOPMENT DEPARTMENT TIGARD Building Permit Review — Residential Building Permit #: /% S7 I2 Site Address: C$—/0 ,c't() E/I-D,c.P I Project Name: io7c2/0n y ie j C/ fpp a 661 Lot #: Planning Review d 9 Pro osa1: elYeln r,P /nu44 .amat bi/ � 7`— i&xr1 I V Verify address/suite# active in Accela. n River Terrace: No ❑ Yes,River Thrace Review Addendum . Sit/Plan Elements: Of osion Control opies of site plan on 8-1/2"x 11"or 11 x 17"paper h1`'etained trees with drip line and tree protection measures ,prawn to scale(standard architect or engineer scale) h1V'ootprint of new structure(including decks)and FFE orth arrow 11141 tility locations&easements(required for new and additions) VS' address,project or subdivision name and lot number dewalk/driveway approach �' Gcant information(name and phone number)it,t 13 i•cation of wells/septic systems Lo dimensions and building setback dimensions f��p�treet tree size,type and location WI;: .re footage of buildings to be demolished .. reet names 115 Existing structures on site 1111toomer elevations(2'contours if more than 4'differentials) M,'.•t area,building coverage area,percentage of coverage and >1,000 sf of impervious area created or replaced? ❑Yes YJ N impervious area(applicable if R-7,R-12,R-25&R-40) If yes,is a storm water quality facility shown? Yes Mo Ocan Water Services—Service Provider Lette of platted prior to 9/10/1995): `' Required: ❑ Yes,applicant was notified No Received: ❑ Yes 0 No Water Meter Fixture Unit Worksheet—Addigdns,Remodels and ADUs Squired: ❑ Yes,applicant was notified No Received: ❑ Yes ❑ No DC Exemption for ADU applied for: ❑ Yes Received: ❑ Yes ❑ No kjOublic Facilities Improvement(PFI) Permit: Required: ❑ Yes,applicant was notified 4Q No Applied For: ❑ Yes ❑ No,stop intake �I1 .till Use Case#: l,�y 0 Zoning: ', I TA required Setbacks: Front: 0M' Rear: /� Side: S Street Side: N/lAi� Garage: lry:'�Building Height: Max.Height: SU Actual Height: iti.,/zh_ ex andscape Area: % of Coverage Max: Entrance et back no more than 8'from street-facing wall ❑ Parallel to street or offset 45 degrees or less Windows ❑ 12%of area of all street-facing facades Garage ❑ Garage door i ' d widest street-facing wall ❑ Yes ❑ No,o e following ❑ Door extends no re than 5'from wall and there is a covered extending beyond garage. ❑ Door extends no more 'from wall and there. sq ft.window above garage on 2nd floor. ❑ Garage door width is ❑ 12'or less o or less of facade ❑ 60%or less and includes 7 of following: ❑ Covered porch ❑ R entrance Wall offset 0 1'Roof eave ❑ Roof offset ❑ Fire shin 1 Lap Siding ❑ Roof pit ❑ Gable,hip,or gambrel roof ❑ Dormer ent siding ❑ Window trim ❑ Window re ❑ Window projection ❑ Balcony +� isual Clearance \IV 1 rban Forestry an ff 0 ensitive Lands: ❑ Yes No Type: on •tions met prior to issuance of building permit 07 Approved By Planning: = Date: ,:,94 ZCJ Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved 0 Not Approved Revision 2: ❑ Approved ❑ Not Approved I:\Building\Fonns1BidgPennitRvw RES 122419.docx Building Permit Submittal Original Submittal Date: 02-it(!o Site Plans: Building Plans: # Building Permit#: nter building permit#above. Workflow Routing: Planning ? -Engineering Permit Coordinator Building Workflow Sign-off: .Sign-off for Planning(include not s from planning review) Route Application Documents: �cEngineering: (1) copy of permit application, (1) site plan, (1) building plan and / original plan review routing form. Building: original permit application, site plans,building plans,engineer and beam calculatio s and etails,if applicable, etc. Notes: By Permit Technician: Date: 1/7417,0 Engineering Review Cope at building pad: Z 7 D Conditions "Met"prior to issuance of building permit ❑ Easements (encroachments)per engineering conditions of approval and plat L3�Water Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes ❑"No Assess Water Quantity Fee in-lieu: ❑ Yes ❑YNo LIDA Facility on lot: ❑ Yes GYNo ❑ Final Plat Recorded: ❑ NOT Approved by Engineering: Date: Notes: L� Approved by Engineering: J Date: Z//Z./21 Z b Revisions (after Building Submittal only) Reviewer Date Revision 1: 0 Approved ❑ Not Approved Revision 2: ❑ Approved 0 Not Approved Permit Coordinator Review ❑ Conditions "Met"prior to issuance of building permit ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: ❑/SDC Exemption: 0 Received ❑ Does not apply q ,SDC Fees Entered: Wash Co Trans Dev Tax: 0 Yes gYK/A Tigard Trans SDC: ❑ Yes D4J/A Parks SDC: ❑ Yes LIDA ❑ Yes L'OK to Issue Permit 7 Approved by Permit Coordinator: GG�4 Date: Z�/��oZ L L\Budding l Forms\B ldgPermitRvw_RES_122419.docx