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Permit
° Community Development c. n Iz D Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.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.: Zr. PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1) CANCEL PERMIT APPLICATION. �' ►� J REFUND PERMIT FEES (attach receipt, if available). G M INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: LC-a l 00_32-7 Site Address or Parcel #: /1 l0 1 1.S StA . Paa' . Project Name: (col y iv 4u-fo. Qepa; t — Subdivision Name: / 1 Lot #: EXPLANATION: Aw;rnn; f ) errvr. ArAct io C>63 r i f a- LC9 -0 (0 -0o d-3c . Signature: S Print Name: _e�,4A f aeA) / C,�q G� a ✓}- Refund Policy �J lJ 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE. USE : ONLY Rte to S's Admin: Date ?HA= B; ' Rte to Bl.: Admin: Date ' 9® B . rer-,. Refund Processed: Date /I) ? Ic By j Invoice Processed: Date By Permit Canceled: Date (z Z 1// e. By - Parcel Tag Added: Date By Receipt #� J,:. ,f : Date.7 ; pc , Method 6 c, Amount 15 , 5 y I: \Building \Forms \RegPemritAction d c'Rev 07/26/07 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 L UDY V November 4, 2010 Bear Electric, Inc. PO Box 389 Donald, OR 97020 Attn: Stacey Wisdom Re: Permit No. ELC2010 -00327 Dear Stacey: The City of Tigard has reinstated the permit fees on the above referenced permit and charged your credit card for the following: Site Address: 12184 SW Morning Hill Dr. Project Name: Spring Fees: $79.54, credit card receipt enclosed. Thank you for your assistance with this matter and my apologies for any inconvenience. Sincerely, r ic);1 7.7.7 Dianna Howse Building Division Services Supervisor Enc. Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard or.gov • TTY Relay: 503.684.2772 ~ CITY OF TIGARD RECEIPT n E 2 . _ 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 178533 - 07/01/2010 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2010 -00327 $79.54 Total: $79.54 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 611092 DHOWSE 07/01/2010 $79.54 Payor: Bear Electric Inc. Total Payments: $79.54 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD RECEIPT I, 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 180213 - 10/29/2010 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2010 -00327 $ -79.54 Total: $ -79.54 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 611092 DHOWSE 10/29/2010 $ -79.54 Payor: Bear Electric Inc. Total Payments: $ -79 . 54 Balance Due: $79.54 Page 1 of 1 CITY OF TIGARD RECEIPT n 1 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD ( ful// 4 -- Receipt Number: 178533 - 07/01/2010 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2010 -00327 Branch Circuits wo /Purchase Service or 2200000 -43103 $71.02 Feeder ELC2010 -00327 12% State Surcharge - Electrical 1003100 -24001 $8.52 Total: $79.54 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 611092 DHOWSE 07/01/2010 $79.54 Payor. Bear Electric Inc. Total Payments: $79.54 • Balance Due: $0.00 Page 1 of 1 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 4"' f jrnkil November 4, 2010 Bear Electric, Inc. PO Box 389 Donald, OR 97020 Attn: Stacey Wisdom Re: Permit No. ELC2010 -00327 Dear Stacey: The City of Tigard has reinstated the permit fees on the above referenced permit and charged your credit card for the following: Site Address: 12184 SW Morning Hill Dr. Project Name: Spring Fees: $79.54, credit card receipt enclosed. Thank you for your assistance with this matter and my apologies for any inconvenience. Sincerely, Dianna Howse Building Division Services Supervisor Enc. Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 (: t VO.1.X)32 - + City of Tigard, Oregon • 13125 SW Hail Blvd. • Tigard, OR 97223 n l • October 29, 2010 -- - Bear Electric PO Box 389 Donald, OR 97020 Re: Permit No. ELC2010 -00327 Dear Sir /Ms.: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: /8 /dye/ sev /o/z Nrn/6 /fiL-c— Vg- • Project Name: Canyon Auto Repair Job No.: N/A Refund: ❑ Check # in the amount of $ ® Credit card "return" receipt in the amount of $79.54. ❑ Trust account "deposit" receipt in the amount of $ Notes: Permit was created in error; added additional fees to existing permit ELC2010- 00230. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 1: \ Building \ Refunds \ Administration \LtrRefund- CancelPermit.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 >'! CITY OF TIGARD • ELECTRICAL PERMIT Permit # ELC2010 -00327 COMMUNITY DEVELOPMENT 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued. 07/01/2010 :TIGARD, 9 Parcel: 2S104AB02100 • Jurisdiction: Tigard Site address: 12184 SW MORNING HILL DR Subdivision: MORNING 'HILL.NO.'2 Lot: 55 Project: Spring Project Description: (3) branch circuits to reconnect A/C or heat pump, service outlet and electric furnace Owner: FEES SPRING, ROGER & DEBBY Quantity Description Date Amount. 12184 SW MORNING HILL DR. TIGARD, OR 97223 3 crt Branch Circuits 07/01/2010 $71.02 wo /Purchase Service or PHONE: 503- 590 -9507 Feeder 1 ea 12% State Surcharge - 07/01/2010 $8.52 Electrical Contractor: BEAR ELECTRIC PO BOX 389 DONALD, OR 97020 PHONE: 503 - 678 -1355 FAX: 503 -678 -1108 Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: • Total $79.54 Required Items and Reports (Conditions) 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 issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by. the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: '- Permittee Signature: ON /97 G / Ce9 7O OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE'OF SUPR. ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m. foran,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. City of Tigard T I G A R D Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request. Refund requests are due to Accela System Administrator by Wednesday at 5:00 PM for processing by the following Wednesday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing. PAYABLE TO: Bear Electric DATE: 10/14/2010 PO Box 389 Donald, OR 97020 REQUESTED BY: Dianna Howse Branden Taggart TRANSACTION INFORMATION: Receipt #: 178533 Case #: ELC2010 -00327 Date: 07/01/2010 Address /Parcel: / 2 / 89' .C44.) Pay Method: CreditCard Project Name: Entr R90/ M1A/& • Mt SP/2/ AfCr 1S■e EXPLANATION: Created permit in error; added additional fees to existing permit ELC2010- 00230. Refund 100% of permit fee paid. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000 -43104 $ Amount Electrical Permit Fees 2200000 -43103 $71.02 12% State Surcharge 1003100 -24001 8.52 TOTAL REFUND: $79.54 APPROVALS: If under $5,000 Professional Staff If under $12,500 Division Manager If under $25,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: I Date: 1 jtf��';',/, 1 By: 1 I: \Building \Refunds \RefundReguest.doc x 09/01 /2010 06/29/2010 15:10 503- 678 -1108 BEAR ELECTRIC PAGE 01/02 • Permit t . .. _ Y c!ltioni , ` 1'tDtt‘ QI Ttet� i.)SF 0NI °: lC:.II J�3 r �� , b C1 DA .{ 11 }1 [•�1 rteng.cavoi v� :r ... ' , . "• J . • � i4' pataiit:• / / d P'umdd'`o 4 &/, 9O :, Q 191 5,SW Halle Wie.i1 'nod Bawd c! 1: 9i 'r a•.� .. I how; 50 r 639.1171 F� ` 503,5. ;',1961: Dat'Jt31: thhirBttnt,y/7�C � �J�/OZ.:J 1 8 1.. a •,TIG p so3 s9al''..' 2 9 20 t), eiioaatyll3y . Juna 1 , �' ®$cr PaCc2 rar ' �.we,.a lrltc : . Nilrfie a 1 .. . . nStl lvtv»,tlpard Or:�nv :� d Jl4etbud=_ Sppplemrnt591grormtiori. TYPE OT :wf?12� (4R �.l °s�'lr�i'1' - N A ra avr: • Pt taxcti casi dl fh61aorly�subrttit'l,' EAfs ofMar * w /u ,inscllecked bela+v), 1flatrttcuon �. Jl�flliitrsn t. ,t34mlrcpy�c�tbcnt. t�, V t i-� •. ,. ' r •fvYllci don mr,ps Or'rttpra © Tlinldtnp t7y�r three Tones,: iJ ©Service o • Q •DC711o1ittort 0; titiier;. wltarcrlid' v^ntalrlo.G,ultCtin 1i 02413uenas 'mdbovty7rda;'' • :cAT EGOF_w Ol± CUNS I1WUCT[O cxcecas to oo •amps at tid;kolts •oi '1].Flo:q,ng •h,xitdm�F � .. less ia'gennnd' or, rxl reds IR;Ogp [] Crnnm i aprfrttiiitxpl 't 1 •ind2 i u rilli lvduoll a ng' COrnmcrctil /ii is ill ❑.Acccssorvbin id.ittg, •ampsforatlofhcri z,stxtlationx, burldmjs , ❑ 0 ❑ h d I ,ar pi>tz 0 • lnslsltactart'of 7 5 7C .ti 4 # syS1tl41 f1tt161V M islCr hiJddcr [ ]i sarrt,cricy sti tem, orltas scOOli t o r .i.rdsylcm .': ,,. ., .::;,. fi .1 It_11 {11!i3'4.N •[IR•■• A I;OCXC7'(J ' ' 'flAddirionof fond of. o "i1 !' '1.2 - f . ,: • � atttPcty: t QOFiP:px more . �OiJTIDa: O6 I� A , L ` S.' OA . t csiror DEtertpat=r>;int'tnbieliiiads'•- • C.I . /S1iitu/L I � . . s b 1letat3a Gn !s t7ifirs„ 0 S upply wlrapr ibrniorc then I ��` � .� 2,..?._____ ❑f lan dti is ioraFioris: • . ' tiOO �g11S "sPminsll... • • SU41;11ki ./ t pt go.; • "'Projt t ntut'1c: 0 svrm� or 1'n Coo arnpY et.:piorc • trcC,:SCit•Ei F� • Cross Ne irmn� gt wle rnu t .ctn,�ct/direeliott5 to]ob. Q! . 1��l11�l�t� - , 'yv csi sntiisl IlE- [amllyttwcllilty;`trtttF' •• - anctndts :nthIci cd g+ Subdiviiton: 1..61 Ni p::: ' 1:,000q ,, f or less . ® 168, , �� • . . . l a t...dd1 :500 a . • E .. orpnttior', 33.92 xi. ax fl plpurC�11DC1` 1 ,miiedcncr�,5 ' r,Oidi.ntta! . DE tkiii 1(1t�,;OF HMO .. t , � .. : Ith •• . • .,�: • ; . 1wi1h atSU1Y� X .,IL1 • l tinited.enr nturtt farnih Cr g s " ; • reSidQnU9�i11ra1wtYU Cfr: x SCn' it CSarfcedcrs .tnxtull:itiuti;'alictalitln tatifo^ rekkatinti \~ Ihil i tot: ■ 200 Rntps ar •tess: 10070 2 . 0,1 / • p, ❑; TEitir1 71 201 • amps:ta,At70 'ant s. t� 56 2' . 103 amps .ta 600 .1ibpa 200.34 2 ] raltiv; � ■A/AitT . ,6 01 anips•ta i aiups 301.04 • 2 A .. . . .. . • ddr ,'0lcr 1 000 amp :orvv . • ' 552:26 2 . Jf jr., ; � 7!en SCrViCC9 or fcede,rs ittstallattort, aitrrnitQrl,4ittUur' retocatit >rr • ltr? � , .. °p • 200 mtpsarlc$5: 5436: . .wrter nstnllatinnt 1 his instsallatsoil3s b .tn mute oon ., c up c ity th it'i own' tiv}lirih is twit 201 art1Ps m4110 rini11 I aS 03 2 • .0 Owl) , 1 01 aniRS 59.9.iun s .. : 16854 2 intcnclutltor a1c,.(ccue,re '.. ... at11;t ccotdtn tra:t?RS 447,.aI.19.670 d'7 • anCJ 1, 1' ' ;liraneh- crrcUiLg- new. alteration. or rY:teoxiinh. UCr 11ut1r1'. .. Q1vr:r signnt.urx .. , ' Datc:r - -.�. - .. ` .11 kpc :,ftitbtairtch circw • . .. .. i- ,. , abtiv. Servicc pc ILcdtr fu. - . . r , .. . . 1C.' ?cT m Coz r�twr > .1t5 t . . " - each brant:lr citcatt is .. Pain lamc . F r rr o it sarvtce• r f • : .. 1 , Coa sc tint .• ' ftrlr branch c1ic11i1 _ i_ . 1 SCrT8 r�'Q v ' t' ., . . l ach.tild'! bruidt •ciruut 7;42...i. 72 • } .- . , - fltitlrLS� lIlaccl3tinC0ux s�riva t >1'ieKdcc ttu't rnCluded Git /tit tvIZIP . 1 lyrmanuractured or madular G7 4 . . dweltln an Sr r1nC >b6i,Li (' )••: - PLI'i• • (. ) Recant et, on1v d/or f, 67.84 ?; ci! =matt: ■• orgntllac tanhi • .. • Ct1er cr inul i9tf u� ropt a Bttsiti65 ti*ric :.::. 0 , _ . V • .. • to p. o i"lditrl . . .. . �0 a ticnsia� [3cscr T"agi . 'Each s) ins eclion toer.stIto able In merit' the above. ' '' + it + hcraaspccuon • pltrtnc;,( • • 1 «' r � Ksh�tilton rCl haul. {t hr 66 25 �► * ! ® 781, . l , ■ �� a�. ) S u.ry Llc:: :: LteTR1CN ..1 "P.,LRNIIT.,EE5� ",:�' J ■ Supty glcLtrti.tali s Ignatu , - r.,rcntr►retl: - — i 51tb Dint t � ` r M rttl p yr'rcvic (25 �o of lini tt tt�) ; I'.nnt name i 1111 1 >4f r Stitt surc lrir o (11 o o p ) i ! / e � ntlicrrtzetl.. ignaturC. . . • 'COTAI PClth11'1 h��., 1 111111; - This m rmicipptic3ane%pirF i rim permitis not obtained Ni '. l rint rfclillct.: ^- .Numiurnfir c alla+v tt li•'W1t:' rr:. • I)a1L' do s a.ftrr h ha t bcrn fitl s'rm e stdin V"csmiaVl.C Pda%rrPPd ' ta'vi3O9 . - 4:0451 ±T(tl +ngrc.CO.l001 ' PI _ " City of Tigard T l G A R D Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request. Refund requests are due to Accela System Administrator by Wednesday at 5:00 PM for processing by the following Wednesday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing. PAYABLE TO: Bear Electric DATE: 10/14/2010 PO Box 389 Donald, OR 97020 REQUESTED BY: Dianna Howse Branden Taggart TRANSACTION INFORMATION: Receipt #: 178533 Case #: ELC2010 -00327 Date: 07/01/2010 Address /Parcel: %02 / cy Seth Pay Method: CreditCard Project Name: C /Ile/2Ni h L i— .sP2t1.rFr h . EXPLANATION: Created permit in error; added additional fees to existing permit ELC2010- 00230. Refund 100% of permit fee paid. REFU1vD INJ RMATIO.N ;. ... . • .. , . ' • .. : Fee : De`ec iptioi :-Fromm Receipt: • Revenue Account-No: - . E 1e • Bu.ildin - ' , Pe r . i ,,ee '. Ex lec- 230000- 43104 . ;=: :;: $An ount�� Rey .... .g- ... t'F ,... - -.. : ' . . p. 0 , .... . _ _. ,. .- Electrical Permit Fees 2200000 -43103 $71.02 12% State Surcharge 1003100 -24001 8.52 TOTAL REFUND: $79.54 APPROVALS: If under $5,000 Professional Staff If under $12,500 Division Manager If under $25,500 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: I /0. ;.7. ',. I By. I I: \Building \Refunds \RefundRequest.doc x 09/01/2010 . City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 Tall CATtin October 29, 2010 Bear Electric PO Box 389 Donald, OR 97020 Re: Permit No. ELC2010 -00327 Dear Sir /Ms.: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 11643 SW Pacific Hwy. Project Name: Canyon Auto Repair Job No.: N/A Refund: ❑ Check # in the amount of $ ® Credit card "return" receipt in the amount of $79.54. ❑ Trust account "deposit" receipt in the amount of $ Notes: Permit was created in error; added additional fees to existing permit ELC2010- 00230. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. • 1: \ Building\ Refunds \ Administration \ LtrRefund- CancelPermit.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 . City of Tigard T l G A RD Accela Refund Request This form is used for refund requests of land use, development engineering and building application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request. Refund requests are due to Accela System Administrator by Wednesday at 5:00 PM for processing by the following Wednesday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing. PAYABLE TO: Bear Electric DATE: 10/14/2010 PO Box 389 Donald, OR 97020 REQUESTED BY: Dianna Howse Branden Taggart TRANSACTION INFORMATION: Receipt #: 178533 Case #: ELC2010 -00327 Date: 07/01/2010 Address /Parcel: 11643 SW Pacific Hwy Pay Method: CreditCard Project Name: Canyon Auto Repair EXPLANATION: Created permit in error; added additional fees to existing permit ELC2010- 00230. Refund 100% of permit fee paid. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund gxample: Building Permit Fee Example: 2300000 -43104 $ Amount Electrical Permit Fees 2200000 -43103 $71.02 12% State Surcharge 1003100 -24001 8.52 TOTAL REFUND: $79.54 APPROVALS: If under $5,000 Professional Staff If under $12,500 Division Manager If under $25,500 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: Date: j B : rb' I: \ Building \Refunds \RefundRequest.doc x 09/01 /N110