Permit `�,` CITY OF TIGARD
I
4 , ��? PLUMBING PERMIT
'- COMMUNITY DEVELOPMENT PERMIT #: PLM2007 - 00321
TIGARD: 13 125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 7/19/2007
r' r+ ut " PARCEL: 2S 110AB -05200
SITE ADDRESS: 14155 SW 114TH AVE ZONING: R -4.5
SUBDIVISION: HAWK MEADOWS LOT: 005 JURISDICTION: TIG
PROJECT: CARLSON
Project Description: 1 sink to patio.
CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES:
TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS:
OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS:
STORIES: WATER HEATERS: CATCH BASINS:
FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS:
SINKS: 1 URINALS: GREASE TRAPS:
LAVATORIES: OTHER FIXTURES:
TUB /SHOWERS: SEWER LINE: ft
WATER CLOSETS: WATER LINE: ft
DISHWASHERS: RAIN DRAIN: ft
Owner: FEES
JENNY CARLSON
14155 SW 114TH AVE. Description Date Amount
TIGARD, OR 97224 [PLUMB] Permit Fee 7/19/2007 $72.50
[TAX] 8% State Surcha 7/19/2007 $5.80
Phone : 503- 624 -9540 Total $78.30
Contractor:
RAYBORN'S PLUMBING INC
PO BOX 69
TUALATIN, OR 97062 REQUIRED ITEMS AND REPORTS
•
Contact # : PRI 503- 692 -4139
FAX 503- 691 -2328
Reg #: LIC 87852
PLM 34 -166PB
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable laws. 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 work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of
these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued By: li � , P ermittee Signature: U 7 c / � re:�i� �
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Jul. 19. 2007 11:24AM Rayborns Plumbing No.5774 P. 1
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-- Plumbinz Permit Apnl' �tion r-P It v ' . ",',,..,:N.'." , at•. . � 1 lit tOF r �ISF ONL ? i j
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City of Tigard � `k . ' < ri_, Recei 1 Bligni
Date/By: o /r A
13125 SW Hall Blvd., Tigard, OR 97223 Permit No �j! /t6Zeo7 �3�
JUL 1 9 201/ PlanRevi - v
Phone: 503.639.4171 Fax 503.598.1960 //, I 3: f!, Other Permit No..
24- Hour Inspection Line: 503.639.4175 cr cy , • €, �i...I J. Da
Internet www.ct tigard oI.us C= 1 ` / �+ Date Ready/By: r ® See Page 2 for
r l I rr, r9`+ 1'11a v a 1 Notified/Method: la 00404040.40g0.400001
t:Nt,!^ l•, �'•• "•1'1 � •1__ � .r ��° nm� Jrt,1`,� �� -,�jr„ f f 1 r' t � lt;, ° !, �� j ° `�' '��:: ��"' 1 � --�= --
apLty i J L ',III J ...a:,,jl;. 2i a 111, a (� J . { i i" 42,1. ie r: }i1.l. -;; : i.Gl l' 1. "151 �n! r � -�''
atl �: t, �r. � [ _ , .. ii ' , (. ' E , i ` .' fir: 7
.._ .,138 tai, _ !� r . ,t . li 7 }.�r!c�; .S.. � +, r.i�.'.:'<>:���n +,� : I l:r.! �' ;.. :, ■ " > T•'.:•ir`lr. +'�_
0 New construction ❑ Demolition For speelallnformation use ehPeklin
Description I Qty. l Ea. 1 Total
67. Addition /alteration/replacement ❑ Other:
_ New 1- family dwellings (includes 100 ft, for each utility connection)
'.tUiTa�tl. . 9 "�,. - !� Ir y , tu.t{¢r•�I7•P ;tn ^. < ,.itJ:-tr S.� �, 3a +i• l+u+''.; , . 7 .y.. „"•'' �..
i3 ni Q J 1 r K ry r..: E?I III _. ?•t: ;
; �: : ;r ,lb:• .>�K_ " l:ar +�,:= rid,:' fi+ �`} av' ��z •- �_� +rl�„ ;F(.f�33 ;'�je,Te;rf SFR (1) bath 249.20
tat 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
❑ Master builder ❑Other: Each additional bath/kitchen 45.00
d �{ 9 r .r - �•, Fire sprinkler ( sq. ft) Page 2
ft�,
n i �.l:�� 1 } - i i � i Y' I � +�1 � �, F ` r} � : la. n . r "� r_. ' �
if rlLYt TII .. tP!� ...A . _ . ��1 Hf ti�'n'kd;1�G'.• , a(h¢?BliT } l l n �!d (b l` S Site utilities
Job site address: L
1 cc c (ity hift2. Catch basin or area drain 16.60
City / State/ZIP: 715 a. rd 0) 9 2 z( Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: I Protect name: / Footing drain (no. linear ft.: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site .�l,.t�.�.,,�c C.:•,....1„1.4 S--- ' �
- _ Manholes 16.60
Rain drain connector 16.60
•
Sanitary sewer (no. linear ft.: ) Page 2
Storm sewer (no. linear ft: ) Page 2
Subdivision: I Lot no.. Water service (no. linear ft.: ) Page 2
Tax map /parcel no,: Fixture or item
4 -+ 7 1 i! J t +a tf' r 1 ) ` ' (o °�'+•'" � �+ x c 't 0e- Absorption valv 16.60
{ lii I�lr} ; t a fi P a t n t5 it + r l :4 - � - ti r J 1
.1 1' i ' t 4 J: x -= . ...7jt J:;r ?l•3 R ' • 111 ._5fiI .. r ii... � 1-;a i..r.,. `;,, , 1, •' c,, : Backflow preventer Page 2
1 .I q`j�, k d> fcPb Backwater valve 16.60
Clot hes washer 16.60
Dishwasher 16.60
ilk
,f1. " """ + fi 7t - � 1 l ic� ( 5; J + I T x - 771753 71 Drinking ountain 16.60
4Ji i : • r r � y ti4 7x1 4 r l,� �I. l, ., dtil „, (1 {1I tllfn{ to � J - P'+ r • , + t g
.. _ . 6, .n1 ...t..,l1. e„ : aF.£? J' i• r+fC.,,,.,4.N1.ul -.. :.( -:.fir.:;,-..... i. t... 1> u.:t 1. (�
Ejec orslsump 16.60
Name; CT,e07/'1 C r lsci'
Expansion tank I6.60
Address: l i. / /
l ss SC-.l l � � �'(/ Fixture /sewer cap 16.60
City /State/ZIP: l CI el r4/ 7 Z2. ! Floor drain/floor sink/hub 16.60
Phone: (So ) c -' . GS Yo Fax: ( ) Garbage disposal 16.60
: ie� } , ; = - r Hose bib 16.60
:a. �, } �? 1l . iigl iViliil;.vFl rigi ,� :�:.ifftlai!t?L;.rl`'(d1iE) ice maker 16.60
ff i _ ,. • -. /_ 43t Interceptor /grease trap 16.60
Contact name: /77i /111. Medical gas (value: $ ) Page 2
Address: Po 49 Primer 16.60
City/State/ZIP: i� ^ ` 0 R 771; Roof drain (commercial) 16.6 1
Phone: (� ) 49 1,//37 I Fax:: (jam 109/ >-3�� Sink/basin/lavatory 16.60 • A'. i4�
Tub /shower /shower pan 16.60
E- mail:: iS ill • / - .7'1AI`.
;Pit r,'Pip ' n 41.•!(!I•. - jv anrr7r. +li I I ' ^,7 * ryry Urinal 16.60
J; it .! _ _ - : 1 iR 1' �•Z•'ru.s gg r F :m-.n : 141 :11 1 F + ' l,
� _ ili'g is -: -: • _. P� __�. = 6 It y f d i 631' ;;: + J 1 y} > , ' 7 t
�ru n r a7a ,:•'+ Jly tll:. , : . R. r!. h?.( r::�`L'c....,:s;.+i,'r�l_: .t: '•it�!i.r1:11!1:LLLl..'; Wa ter closet 16.60
'. Water heater 16.60
Address: ! r � go y z ? ?IA, !� Other:
City /State/ZIP: A ! 7Q6 Subtotal
G � -� l Minimum permit fee: S72.50
Phone: 3 ) 6 ! - q/39 Fax: $ 3 )67/ -). 3� ' Residential backflow minimum permit fee: S36.25 72 • Co
CCB Lic.: Cr.71 . Plumbing Lic. no.:3/I -// 6 pa Plan review (25% of permit fee)
Authorized signature: State surcharge (8% of permit fee)_ . , �°
y TOTAL PERMIT FEE 7�.3a
Print name: I f l , - Date; 7 / ,_, 7 This permit application expires if a permit is not obtained within
180 days after it has been accepted as complete.
• *Fee methodology set by Tri- County Building Industry Service Board.
i:\5 uilding \Pcrmile\PLM- PermilApp.doe 06/05 4 4046167( IO /0I/COM/WEB)
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City of Tigard, Oregon o 13125 SW Ha11 Blvd. o Tigard, OR 97223 VOX ih
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August 1, 2007 AN' •
Rayborn's Plumbing, Inc.
19990 SW Cipole Rd.
Tualatin, OR 97062
Attn: Lee
Re: Permit No. PLM2007 -00321
Dear Lee:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 14155 SW 114 Ave.
Project Name: Carlson
Job No.: N/A
Refund: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $62.64.
❑ Trust account "deposit" receipt in the amount of $
Notes: Per applicant's request as job was canceled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
7.
Dianna Howse
Permit Specialist
E nc.
I : \ Building\ Refunds \Administ ration \LtrRefund- CancelPermit.doc 01/ 16/07
Phone: 503.639.4171 0 Fax 503.684.7297 o www.tigard- or.gov o TTY Relay: 503.684.2772
•
Building Division
,.� Request for Permit Action or��yD�j��e n W 2 T r {({t 1C1 @ }m
City of Tigard 322wwwmm� q
7 )[U
TO: CITY OF TIGARD I ILIAB►
Permit System Administrator Gay V S
13125 SW Hall Blvd., Tigard, OR 97223 BUILDING pIVIt4N
Phone: 503.718.2430 Fax: 503.598.1960
FROM: Owner n Applicant A Contractor 1 City Staff
(check one)
Name:
1 (Business or Individual) (J`c C L7i.s f 1U'^ti )tcC / <� L-
V I J J
` " "� `MailingAddress: 77 0 j ,) C('p4e
l
f i/ c 7 City /State /Zip: 7US /5 fit' (/ 70 ( z
Phone No.: 0 2 - ` ./l 3
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
!'r 1 i CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: t j4 /.y>, 2007- op3 2/
Site Address or Parcel #: /'/ S s S&' ! / [l f /7(/ •
Project Name: �� r f Say
Subdivision Name: , /c e Lot #: Cja�
EXPLANATION: Cc 1; del' - c/ 4
•
Signature: % Date: 7.- Z c -7
Print Name: ,�Qe Ve 4 l12�c.. , <;LJ'
Refund Policy
I. The Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected .
h) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payer in the same method in which payment was received.
i'-"e~ ; n � 1 �+n+w 3 fi 3�� �K �t ti k.`�5a (>a�K.r - . x a b�^,� �� n � �.� a' uu e ��.0 , �.F 1 7 c �
,; ��,.. , w;� ..a . x . t r rFOR OFFICE USeONLYr1E 4 x IFI a 2Ga x, ,y,r z y s s - t
. g,W� .n;, „� <b�av ��� ��' .�, 7t�,tl`L_, {. � mr.... s ». � ., .. _ - nt _.._.� . _,.� .u', 9t+..1. � cwt ,,.;I: :A'l . »fr ._.:c...nyYr �::."E:d!°(fii'A,n:.�alt51
Rte to Sys Admin: Date By Rte to Bldg Admin: Date e / e 2 By : 17.
Refund Processed: Date t/, 2 By ;ix. Invoice Processed: Date By
Pen Canceled: Date e- r 67 By ,; AI N Parcel Tag Added: Date By
Receipt #09- 335 „'late 7� /Vo7 Method Amount $ ,
I: \Building\ Forms \RegPermitAction- Bld Rev 10/17/05 -
City of Tigard
TIGARD Tidemark Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Tidemark System Administrator by Friday
at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Raybornts Plumbing, Inc. DATE: August 1, 2007
19990 SW Cipole Rd.
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
Attn: Lee
TRANSACTION INFORMATION:
Receipt #i : 2007 -3358 Case #/ : PLM2007 -00321
Date: 7/19/07 Address /Parcel: 14155 SW 114th Ave.
Pay Method: CreditCard Project Name: Carlson
EXPLANATION: Per applicant's request as job was canceled. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount
[PLUMB] Permit Fee 245 - 0000 - 431000 $58.00
[TAX] 8% State Surcharge 100- 0000 - 207020 4.64
TOTAL REFUND: $62.64
APPROVALS:
If under $500 Professional Staff
/-
If under $7,500 Division Manager ■-wopfl A '' ' }t_ k.
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: , ; it 7 BY `
I:\ Building \Refunds \RefundRequest.doc 05/23/07
..'ra
l _--,-:----- CITY OF TIGARD 8/1/2007 •
13125 SW Hall Blvd. 4:02:O7PM
Tigard, OR 97223 503.639.4171
T[GARD'
Refund Receipt #: 27200700000000003555 A'� -,/��. ;�z,
Date: 08/01/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
PLM2007 -00321 Reversal - [PLUMB] Permit Fee 245- 0000 - 431000 (58.00)
PLM2007 -00321 Reversal - [TAX] 8% State Sure 100 - 0000 - 207020 (4.64)
Line Item Total: ($62.64)
Refund:
Method Payer User ID Acct. /Check No. Approval No. How Received Amount Paid
Credit Reversal RAYBORN'S PLUMBING, INC. 095889 Fax (62.64)
Refund Total: ($62.64)
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cReceiptrpt Page 1 of 1
� l
�z - = CITY OF TIGARD 7/26/2007 .
C 13125 SW Hall Blvd. 2:26:O6PM
- Tigard, OR 97223 503.639.4171
TIG'ARD
'€fir =et " —tea
Receipt #: 27200700000000003358 ,/` /6 /
Date: 07/19/2007
Line Items:
Case No Trail Code Description Revenue Account No Amount Paid
PLM2007 -00321 [PLUMB] Permit Fee 245- 0000 - 431000 72.50
PLM2007 -00321 [TAX] 8% State Surcharge 100- 0000 - 207020 5.80
Line Item Total: $78.30
Payments:
Method Payer User Ill Acct. /Check No. Approval No. How Received Amount Paid
CreditCard RAYBORN'S PLUMBING BB 095889 Fax 78.30
Payment Total: $78.30
cReceipt.rpt Page 1 of 1