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PFI2019-00050 TIGARD City of Tigard June 24,2019 Root Excavation 10824 SE Oak St, #322 Milwaukie,OR 97222 Re: Permit No. PFI2019-00050 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 11070 SW Cottonwood Ln Project Name: Halstead Job No.: N/A Refund Method: ® Check#232440 in the amount of$300.00. ❑ Credit card"return"receipt in the amount of$ 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$ Comment(s): Per applicant's request as contract for work was cancelled. Refund 100% per engineering division. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov 71 ■ " City of Tigard TIGARD 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: Root Excavation DATE: 6/17/2019 10824 SE Oak St, #322 Milwaukie, OR 97222 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 421521 Case#: PFI2019-00050 Date: 2/13/2019 Address/Parcel: 11070 SW Cottonwood Ln Pay Method: CreditCard Project Name: Halstead 1 EXPLANATION: Per applicant's request as contract for work was cancelled. Refund 100%of permit fees per Brady Bullinger. ' REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount PFI Permit Fee 640-0000-43114 $300.00 TOTAL REFUND: $300.00 APPROVALS: SIGNS / ATE: If under$5,000 Professional Staff ��j/(J 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: S/1 4=/' By ; 1:\Building\Refunds\RefundRequest.doc x 09/01/2010 511 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Halstead Site Address: 11070 SW COTTONWOOD LN Receipt Number: 434460 - 05/21/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12019-00050 $-300.00 Total: $-300.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 232440 DHOWSE 05/21/2021 $-300.00 Payor: Root Excavation Total Payments: $-300.00 Balance Due: $0.00 Page 1 of 1 IN CITY OF TIGARD RECEIPT F. C .a 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Halstead Site Address: 11070 SW COTTONWOOD LN Receipt Number: 421521 - 02/13/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12019-00050 PFI Permit Fee 640-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 130845 PUBLICUSER108 02/13/2019 $300.00 Payer: Root Excavation Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 /i 7/ii• City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action i ! ( ' 13125 SW Hall Blvd. •Tigard,Oregon 97223.503-718-2439 =www.tigard-tn.gov rd-oc.gov natesamemiumeamomommose TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax 503-598-1960 TiganiBuildingPermits(a3tigaard-or.gov FROM: ❑ Owner X Applicant O Contractor ❑ City Staff Check Mone REFUND OR Name: 1 INVOICE TO: 4sur wl a a9 .i ege1a,VCi r'on _� Mailing Address: 1)82� , a, 522_ City/State/Zip: In Phone No.: 5. (1U PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED(1): .1 CANCEL/VOID PERMIT APPLICATION. �1 REFUN PERMIT {attac copy original receipt and provide explanation below). INVOICED FOR FEESFEES DUE{attachh coffee schedule and provide explanation below). Permit#: ?Fa. 2-0`q -bOC) Site Address or Parcel#: `` �}��O-i )) C ( 1 ..�o Project Name: Subdivision Name: FV ( N o 3 Lot#: 245 EXPLANATION: "W____eSaCe-+L_TtDrjoaRyN. hG.la r ali0A r" Signature: 4 � Date: '24 -i Print Name: atop &ymenichoyo --__ RCfund Policy 1. The th)s Community Development Director,Building Official or City Engineer may authorize the refund of. • Any fee which was erronety+.ty paid or collected. • Not more than 80%of the application or plan review fee whin as application is withdrawn or canceled before review effort has been expended • Not more than 23%of the application or l,a,nit fee for issued permits prior to any inspection rerlursea. 2. All refunds will be returned to the odginal payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. 'ATIw ,,,n"r ''' FOR OFFICE lCE 1:tile ON!:‘ KK s Route to ass ri.dn nt: Date By Route to Records: Dare X 2 • $ �/f Refund Processed: Date 4a f7/Irj By Invoice Processed: Date By Permit Canceled: j Date /r7/ram Bl Parcel Tag Added: Date By kABuiidin Votxns t:eyYemtitAction_I th \ / ! r 7� CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT 1 't COMMUNITY DEVELOPMENT Permit#: PF12019-00050 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/14/2019 TtGARD Parcel: 1S134ACO2649 • • Jurisdiction: Tigard Site address: 11070 SW COTTONWOOD LN Subdivision: ENGLEWOOD NO.3 Lot: 215 Project: Halstead Project Description: Replace sewer from clean-out of the home to the tap of main as a bore Owner: FEES Description Date Amount PFI Permit Fee 02/13/2019 $300.00 PHONE: Contractor: ROOT EXCAVATION 10824 E OAK ST MILWAUKIE, OR 97222 PHONE: 503-656-6610 FAX: 503-656-6625 Applicant: REBECCA SCHOENBOM 10824 E OAK ST MILWAUKIE, OR 97222 PHONE: 503-656-6610 Total $300.00 Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact information of responsible parties before beginning work. Perm ittee/Applicant Signature: See application Issued By: ___._�! Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12019-00050 Tyne: Condition Name: Status: Severity: PFI_Sidewalk/C 01 -WORK SITE REQUIREMENTS Applied Notice Applicant must comply with all applicable provisions of federal and state law,the Tigard Municipal Code, and the terms of any agreement with the City of Tigard regarding work to be done pursuant to this permit. PFI_Sidewalk/[ 02-WORK SITE AREA Applied Notice The work area and approach roads shall be maintained in a clean condition,free from obstructions and hazards. The spreading of mud or debris or storage of materials or equipment of any kind upon any public roadway is strictly prohibited and violation shall be cause for immediate cancellation of the permit. The City may at any time order immediate clean-up and suspension of work to accomplish clean-up. PFI_Sidewalk/C 03-WORK SITE EROSION CONTROL Applied Notice Prior to starting work, effective and approved erosion control devices must be installed and maintained meeting the Clean Water Services and DEQ requirements. The City may at any time order corrective action and suspension of work to accomplish effective erosion control. PFI_Sidewalk/[ 04-WORK SITE REPAIRS Applied Notice Disturbed landscaped areas shall be restored or replaced. Existing signs, pavement markings, mailboxes, etc.shall be reinstalled or replaced, with like kind of material. Obtain City approval of restoration work. PFI_Sidewalk/[ 05-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert Phone#>,to establish a preconstruction meeting. PFI_Sidewalk/[ 06-NOTICE TO COMMENCE WORK Applied Notice The applicant shall notify the City's Inspector twenty-four(24)hours prior to commencing work, prior to any staged inspection, and after completing work covered by the permit. PFI_Sidewalk/[ 07-PERMIT/PLAN ON SITE Applied Notice A copy of the permit including a Certificate of Insurance, and all attachments,and a copy of the approved construction plan and all amendments shall be readily available at the work area. All work shall conform to the permit terms, conditions and provisions and to the City approved permit plans, and approved plan amendments and to the City's standards and specifications and to these General Conditions. Changes to any of these must be approved by the City, in advance of work performance. PFI_Sidewalk/[ 08-EMERGENCY CONTACTS Applied Notice Provide to the City inspector, in writing,the names and 24 hour emergency telephone number of two(2)persons who have authority to resolve problems,take corrective action and, in general,will be responsible in case of any emergency. The applicant shall notify the City Inspector, in writing, of any/all assignment changes. PFI_Sidewalk/[ 09-OTHER Applied Notice ' f ' 1p_. RECEIVED City of Tigard G 7 4 ✓" PUBLIC WORKS — ENGINEERING �/ FEB 0 7 2019 TIL : 0: Public Facility Improvement (PFah1NOF TI RING TYPE OF WORK DESCRIPTION OF WORK(in the tight-of-way) El TYPE 1—Franchise Utility Work Check one: Utilities Sidewalk/driveway approach ❑Srreetimprovements performed by NWN, PGE Detailed description: Swer.firprn eleAr,•w and/or utility agency. TYPE 2—Sidewalk/Driveway/SewerVI� C. 40 'I noun••Ae5 tor-t Work performed for the purpose of: • Sidewalk installation or repair. • Driveway approach installation Property address/location(s): 11070�c�lifY e C) t and/or repair Ulm r 1 U _ip8 • Sanitary sewer lateral installation j����( and/or main line tap Applicant:M(tb( ubweio( El TYPE 3—Full scale Development Work performed with Land use Address: ._I be)2� se �� �}n_ y� approval which includes any of City/state: L4j_lWrataC . C�12 Zip: -1 f 2. !L the following: Phone�(1}� trJUn Email; tt • Subdivisions or Partitions Contact namQIYL Phone: — C • Streetwidetin Q g • Mainline installation for Sanitary Contractor: Ru r Vi 1c6 bA' Rook- t.xCv[ i sewer, Storm sewer, Tigard water and/or Tigard Water Service Area CCB#: ..11 .. r Expiration: Address: lint SE OctK 32,1_ SUBMIT COMPLETED APPLICATION TO: City/state: m I I IA/ci.ikii I t. O Zip: G 1 7JJl City of Tigard Phon (p (pie(OEmail:f);C.d.& r la AVI(•c.V f( Planning/Engineering 13125 SW Hail Blvd. Contact name: Phone: L Tigard,OR 97223 Applications fin "minor work in right-of-way" Engineer:_ only may he mailed to: rowpermits@tigard-or.gov Address: FOR STAFF USE ONLY City/state: Zip: t ,, ,—v� Phone: Email: Case No.: PrlC•2t�19—=C Contact name: Application submittal fee(.07%of r ��1 Engineer's Estimate) $ __ Estimated value of worlds required(if over$5,000):$ NOW) Additional fees:.$ O6 (within the public right-of-way) t`"1' Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes )(No $y` Date: �l�f t If so,please specify(l-U P,SDR,SUB, etc.) case#: Application renewed: By: 613 Date: 2. o�!f/2 Of / Is work related to a BUTT DING PERMIT? )(Yes ❑ No Applicant notified: I if so,please specify(BUILDING PERMIT)case#: By: __Date: -21))/)ci P.�NF`,Pa-mtFhp;iiceTmmApi,apnl icatton n'ectie10(6/ZO1] eR as c.:rn: ,. ...,, m--�.ras,c;»: 'anuw...tr:asr,:,�x=. ;.^?rvraxn a:axc:n:ax,en-nsz n•:_ ..... _. ,: max• City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-ot.gov • 503-718-2421 • Page I of 4 1 „ t APPLICANTS NOTE: Person specified as`Applicant”shall be designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to TMC 15.041.140. With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,when the owner and the applicant are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner(s) must sign this application,in the space provided or submit a written authorization with this application. Pc.nchised Utilities are not required to obtain the owners signature on the application BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. • All of the above statements and the statements in any plot plan,attachments,and exhibits transmitted herewith,are true;and the applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such statements are false. • The applicant has read the entire contents of the application,including the policies and criteria,and understands the requirements for approving or denying the application. &W4 &‘/ 10 I l-eibeCtet 36 I oeYI ► L ' t q Applicant/Authorized Agent's signature Print name Date SIGNATURES of each owner of the subject property, if required. Owner's signature hint name Date Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4 a�tBC°und Plumbing c T,2� V1, s‘# *It4'-��e1 . lc 1J lJ ` I yJQ3-638-0t#a5(37) _ FAX.503-656-6025 f3., 1 1 CC• kEXCAVATI ON) AS-BUILT DRAWING Plumbing Uceny 3 b • . _ tt- : • , i I r i .. �w JSj ..... _ r � t 7t t • -_ .J'-_ _.._._ -.-.- - • A. --- • 1__ 1..�, i } . �3E'tka [1+1 K.(�jTC4,Cl2th4 _ , I • 1 ' 3 3 ! 1 t