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Permit r YW ,1.J VV l,� t Qc5 . ' _� 0 bO -� CITY OF TIGARD PLUMBING PERMIT y 7 4 =' COMMUNITY DEVELOPMENT Permit #: PLM2009-00183 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/10/2009 TIGARD Parcel: 1S136CA04600 Jurisdiction: Tigard Site address: 10990 SW 79TH AVE Subdivision: FRIENDLY ACRES Lot: 2 Project: Combs Project Description: Install (1) w /c, and (1) lay. Owner: FEES COMBS, TYLER Quantity Description Date Amount 20908 SW WINEMA CT TUALATIN, OR 97062 1 ea Lavatories 07/10/2009 $16.60 1 ea Water Closet 07/10/2009 $16.60 PHONE: 503-545-4177 1 12% State Surcharge - 07/10/2009 $8.70 Plumbing Contractor: 39 ea Minimum Fee Adjustment - 07/10/2009 $39.30 OWNER Plumbing PHONE: FAX: Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $81.20 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: Un Permittee Signature: C „ Q Q 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. I I CITY OF TIGARD PLUMBING PERMIT Ill r - COMMUNITY DEVELOPMENT Permit #: PLM2009 -00183 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/10/2009 TIGARD �R' Parcel: 1 S 136CA04600 Jurisdiction: Tigard Site address: 10990 SW 79TH AVE Subdivision: FRIENDLY ACRES Lot: 2 Project: Combs Project Description: Install (1) w /c, and (1) lay. Owner: FEES ROBERTSON, SANDON P AND Quantity Description Date Amount NOYES, PAMELA S, 10990 SW 79TH TIGARD, OR 97223 1 ea Lavatories 07/10/2009 $16.60 1 ea Water Closet 07/10/2009 $16.60 PHONE: 1 12% State Surcharge - 07/10/2009 $8.70 Plumbing Contractor: 39 ea Minimum Fee Adjustment - 07/10/2009 $39.30 OWNER Plumbing PHONE: FAX: Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $81.20 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 ( oor 1.800.332.2344. c----....... Issued By: . (� V ci A '/) X n ` ` / .� n 1J (� n I � Permittee Signature: \ /1 y ( Il r \ Call 503.639.4175 by 7:00 a.m. for an inspection that business day. App._ 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. 001 _ Oa/ (f City of Tt ard, Oregon 13125 SW Hall Blvd. © Tigard, OR 97223 WAttitalVoiNi 2YhY.'' t' $ -r. - � r � SY t tl EA �JVF,� � .YF+ �00 y4 September 11, 2009 61MSS# 4A. ; Tyler Combs 20908 SW Winema Ct. Tualatin, OR 97062 Re: Permit No. ELC2009- 00336, MEC2009- 00337, PLM2009 -00183 Dear Mr. Combs: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 10990 SW 79 Ave. - Project Name: Combs Job No.: N/A Refund: ® Check #100517 in the amount of $177.86. ❑ Credit card "return" receipt in the amount of $ n Trust account "deposit" receipt in the amount of $ Notes: Per applicant's request as project was cancelled. Refund 80% 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 0 www.tigard- or.gov © TTY Relay: 503.684.2772 III Community Development RECEI Request for Permit Action TIGARD JUL 14 2009 TO: CITY OF TIGARD CITY OF TIGARD Building Division Services Coordinator BUILDING DIVISION 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: VI, Owner \ P Applicant n Contractor ❑ City Staff (check one) REFUND OR Name: .._ INVOICE TO: (Business or Individual) / eir �Orn4_51 Mailing Address: 2090 $ S14/ 1 I ''t C.1 City /State /Zip: " FA / g f /, q 7o 61. Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): n CANCEL PERMIT APPLICATION. �, REFUND PERMIT FEES (attach receipt, if available). n INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ft, 1 2 C I O 1 . 0 0 1 g 3 • Site Address or Parcel #: / 3 / 3 4 C IS 016 00 /0990 set) 29 XE Project Name: Subdivision Name: /1 Lot #: EXPLANATION: kit ' re- VI toe of 4€ p i0 eC r ' f 14A✓(t P.3 J Signature: Date: 7 e Print Name: 1' /Q Covilb5 Refund Policy 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 Sys Admin: Date By Rte to Bldg Admin: Date ///`09 By_. y Refund Processed: Date 9////09 By ��� - Invoice Processed: Date / By Permit Canceled: Date /j //Q S By r' ' Parcel Tag Added: Date By Receipt # Date Method Amount $ I: \Building \Forms \RegPermitAction.doc Rev 07/26/07 Plumbing Permit Application Building 'Fixtures � 1 V 1 FOR OFFICE USE ONLY` • City of Tigard Receiv • " / �, C' oCi ty g JUL 1 0 2009 Permit No. V 13125 SW Hall Blvd., Tigard, OR 97223 Date/By: Review C .. Phone: 503.639.4171 Fax: 503.598.1960 CITY OF TIGARn Date/By: Other Permit No.: Inspection Line: 503.639.4175 B UILDING DIVISIO /+ • T'I GAR D N ate ied/Met lurk,; \ S See Page lementa l Information for Internet www "Bard or gov otified/Metho '� I ' Supplemental Information • r " , eN 1 ,;.. : t+ d .. z. s. xr z., .- +' "z+.° rt ,,�,r, # � _- _ e ° ,,:::� < v; o ; .t a : r .T , .� w , -:'.as* t *,.• as t n a^ . 5 ,zt-. e , t�,_: .e , ., T,YPE O "W �-� 1 � q 3A - W ;.F SCI' - tE DU L) ' ' � ,r . �..r�.. . �&.,, �..: �... �.. �., n.. ax.. n.-„ .>1w��x�r<�.,�..�aa� >..xr,�:�� ,,, - - : � . �-�,�� �a, .<d4tiw ,. � sz.;.:- e. :. a- �. �.-. �r��„- �. a. �. era.�,.�.�....�.,���s`.��'��:. ''..��n�t�,n >t5. ❑ New construction ❑ Demolition For special information use checklist Description Qty. 1 Ea. 1 Total ❑ Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) , c" � ; '`g�CATFG�ORY ® CONginef ON �-` `V ah x` SFR (1) bath 249.20 ❑ 1 - and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 ❑ Master builder Each additional bath/kitchen 45.00 ❑ Other: �' '"', �a Ruzc ad �v- t' 4 - �.�- 's'° #� �" �'•v r":.r+� � d«..s -.` Fire sprinkler ( sq. ft.) Page 2 g � 11 4s k � - JOB E 7NFU T Ia ti fell i l i OC , V i g i Site utilities Job site address: /eMq 0 s' (A) 11 fl•-■ AUL , Catch basin or area drain 16.60 City /State /ZIP: 77&,Q/Zl7, D 7 ZZ 3 Drywell, leach line, or trench drain 16.60 _ Suite /bldg. /apt. no.: I Project name: COn/t,i S F ooting drain (no. linear ft.: ) Page 2 Manufactured home utilities ' 110.00 Cross street/directions to job site: Manholes 16.60 AVE-4r2 ThC � G "( oar 0 H Y r6OIC Z17 � ^�^ Rain drain connector 16.60 ,o ..{ &7C -(., Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Subdivision: Lot no.: Water service (no. linear ft.: ) Page 2 Fixture or item Tax map /parcel no.: Absorption valve 16.60 , nn :, • I � , ! D / ESCR��IO ratW m K Backflow preventer Page 2 A0L t A` • ✓IP vhf .i51 I e -- G1'n0,� r-� 1/ /x Backwater valve 16.60 J Clothes washer 16.60 • Dishwasher 16.60 ' ,,RMAVPFeWf tOWWE"RR :� 1? IPI �� $ 'j TENANJ'j k if, V Drinki fountain 16.60 ` Ejectors /sump 16.60 Name: TyL 6g_ CO/t t,rf S Expansion tank 16.60 Address: Z Oboe S (44AJ( -..4a4 C'T. Fixture /sewer cap 16.60 City /State /ZIP: 7 J1t. ,AY //U / 0 le et 70t 2 Floor drain /floor sink /hub 16.60 Phone: ( Sa) S LI S q ( 77 Fax: ( ) Garbage disposal 16.60 v x . - -; x� r r^ s ivA v Hose bib 16.60 �tt tPT I GANT f 4 5 GON r AGTPERS0 ` € , . - _ • Ice maker 16,60 Business name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 16.60 City /State /ZIP: Roof drain (commercial) 16.60 Phone: ( ) Fax: : ( ) Sink/basin /lavatory 7 I 16.60 /6 , 60 Tub /shower /shower pan /Wt 16.60 E-mail: Urinal 16.60 g t M ', *J CONTRACTO *� R '",` ��; �re $4 . (g,. CO aG 744 1 s,x .- -._ _.OZ . ;, :..� ; » >�. . .. rw ,, ,. a .� .. ...., , .� ..r , „i :1.. 1 Water Closet / 16.60 Business name: I Water heater 16.60 Address: `/�l// Other: City /State /ZIP: Subtotal �� .ZU Minimum permit fee: $72.50 Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 72'50 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) �/ State surcharge (12% of permit fee) R.70 Authorized signature: /v0ct• TOTAL PERMIT FEE V Print name: Tye. C a44 S Date: ,TVL y / U/U4 This permit application expires if a permit is not obtaine within 180 days after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. 1: 1Building \Permits\PLMF- PermitApp. doc 12/27/06 440- 4616T(10 /02 /COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: j° •rR' "a a -... s ' �*"` i - r ° ='i£n* �. "'SY+'P'z -- �;`'.e 4, S ;,�:;:a'.x S.tei.Ttihtles r - Q' Fee `(ea)' 1 TOtal, i _ _ ...��..::...'psd ,.... 'aa. � .8 ��,_.��9 �� ��� �.�. Square Footage � � Fee va � �, z., Footing drain - 1 100' 55.00 0 to 2,000 $115.00 Footing drain - each additional 100' 46.40 2,001 to 3,600 $160.00 Sewer - 1st 100' 55.00 3,601 to 7,200 $220.00 7,201 and greater $309.00 Sewer - each additional 100' 46.40 Water Service - 1st 100' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Vaf ti j x" < A s _, PermitF '.� Storm &Rain Drain - 1st 100' 55.00 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each F1xture^orJtei ' f A-1 t Qty ee (ea) t Total additional $100.00 or fraction thereof to and tr ... .. including $10,000.00. Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to (minimum permit fee $36.25) 27.55 and including $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for Inspection of existing plumbing or each additional $100.00 or fraction thereof, to and including $50,000.00. specially requested inspections - per hour 72.50 $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for Subtotal: each additional $100.00 or fraction thereof. Commercial Fixture Work: p R �ro I � �' fan ev tewforP umb><iglnstalations > Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following. please indicate work performed by fixture. Failure to Please check all that apply. accurately •report fixtures could result in increased sewer fees *. CD Army new commercial building with water service 2" and )' ' r `` l Quantrftiby (Ftxfure)"V9A- Uirformedf : greater, except systems designed and stamped by licensed ;FIXtUI'e Type s ,, � m ,-. � .' is izt wok t �' Rep1aC engineer. emit, t J .. �,,A . . Previous Capped Added +tk; .:13 sefn ❑ New exterior plumbing site utilities for any complex structure Baptistry /Font as defined in OAR918- 780 -0040. Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash - Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. - Drive Thru Cuspidor/Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher . - Commercial Domestic J � Drinking Fountain , lACt letl'1COr, I se�Dlagra oftMgiv Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain /sink - 2" that meet the qualifications above. -3" -4" Car Wash Drain - Garbage - Domestic Comments regarding fixture work: Disposal - Commercial - Industrial Ice Mach./Refrig. Drains Oil Separator (Gas Station) • Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - Toilet • Urinal Other Fixtures: 1:\ Building \Permits\PLM- PermitApp.doc 12/27/06 ir Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.055 (4)) i This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or g:=1 will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. T( C L c Y Print N me of Permit Applicant ri/ ( -)nlh 745/°71 o P / I Sig a re Applicant Date • ti1C2_00 t • (-1.- ) 6(.a, , gyp. Permit #: 00 a. .•. (A It. ea Address: z w<��iv,A 7 �( Otglt c? Q17.23 +�.. :; � _. I, Issued by: Date: 7/10/69 E, This Copy for Permit Offices City of Tigard, Oregon 13125 SW Hall Blvd. 0 Tigard, OR 97223 • 11 • .{ • September 11, 2009 Tyler Combs 20908 SW Winema Ct. Tualatin, OR 97062 Re: Permit No. ELC2009- 00336, MEC2009- 00337, PLM2009 -00183 Dear Mr. Combs: - The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 10990 SW 79 Ave. Project Name: Combs Job No.: N/A Refund: ® Check #100517 in the amount of $177.86. ❑ Credit card "return" receipt in the amount of $ ❑ Trust account "deposit" receipt in the amount of $ Notes: Per applicant's request as project was cancelled. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I: \Building\ Refunds \Administrat ion \LtrRefund- CancelPerrnit.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • • www.tigard - or.gov • TTY Relay: 503.684.2772 7111 q City of Tigard T I G n R D Accela 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 Accela System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Tyler Combs DATE: 7/16/09 20908 SW Winema Ct. Tualatin, OR 97062 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt #: 174306, 174307, 174308 Case #: ELC2009- 00336, '/ MEC2009 -00337 • PLM2009 -00183 • Date: 7/10/09 Address /Parcel: 10990 SW 79th Ave. Pay Method: Check Project Name: Combs EXPLANATION: Per applicant's request as project was cancelled. Refund 80% of permit fees. - �, '1' �- - ��: ,'PI.4 .. �.. . �"', :? 'i!' -'. t;.':•... • '.t +,� :ew•t c �R: ,-.. I�f xs}���('1'y /, ,• „� N,:- f•. ••.F._�. _i'�''; -. •"_ '�l3 :�:Y• �:':,;;`� -'•' F..� s.� 'r �,'. ::�. } .{. ' _ ._5.... � C� 11• ���I�OL..ut�f :��Oi'.,?. • 'ii, b R �'1!��:'�` Ji'. .!(.A./ • 14-` R�I�.r r r�.. . •�. f�.'�.' "- 1'XA�. .� � J�ii�. ': : . : �;p�s -'Aw'!jf$'+ :° y r( �Y 7 ^ -;.•- :u•, !s• ` . •-ti - .-- ,?'vi ,�;• _ a � : ; ;'.:-'.p` -- f_. 'e a g' ' :: .Vi:,.: . :'.R ciqunt . 'y, ^,- ` r# faL in. i .4, 1 }': rt . :. ;; , ..•S .,.rl ,.i. ;1'.. i fl.'1� : f: f}L'� ' L,�. � ,'i. =�+ ?_1 '�. 'r�.;+:: r_.1� . { » >._7 :f�.' ', _ .;::1 � - .�.i;.:5. ' -F��. t':,. ;, ;: . . : •' y_ _ . ,: . .$. _Ar m'aju ' ��: � � �,`- 7 .�]� I ?. � mit Fee ;: ��- �. ,�:;:?.. ,.. � Ex at�i pl e : 24 5` =' 0.0 0.0 • :._32Q00•`' : • • ., �,. :. ....,..... 0A Electrical Permit Fee 2200000 -43103 ✓ $42.80 ✓ 12% State Surcharge 1003100 -24001 ✓ 5.14 Mechanical Permit Fee 2300000 -43102 ✓ 58.00 12% State Surcharge 1003100 -24001 ✓ 6.96 •- Plumbing Permit Fee 2300000 -43101 $58.00 •• 12% State Surcharge 1003100 - 24001 ✓ 6.96 TOTAL REFUND: $177.86 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager , I len .. If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board ONLY: . _. •;, , ;- ' �'` � �:' t:;.' °F•OR ACGEI:A'SYST•EM ADMINISTRATION: L�S :;' -:; , . .. , • . . Refund Request Reviewed: Date: 2 //C By: ` Case Refund Processed: Date: / ,d.Gd' By: _ e i - ' I: \Building \Refunds \RefundRequest.doc 04/13/09 CITY OF TIGARD RECEIPT 1 111 ! gt . 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD fJ J (Avg) Receipt Number: 175175 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009 - 00336 $ - 47.94 Total: $ -47.94 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DHOWSE 09/11/2009 $ - 47.94 Payor: Tyler Combs Total Payments: $ Balance Due: $47.94 • • Page 1 of 1 CITY OF TIGARD RECEIPT j5 13125 SW Hall Blvd., Tigard OR 97223 • 503.639.4171 TIGARD Receipt Number: 175178 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 $ -64.96 Total: $ -64.96 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DHOWSE 09/11/2009 $ -64.96 Payor: Tyler Combs Total Payments: $ -64.96 Balance Due: $64.96 Page 1 of 1 III CITY OF TIGARD RECEIPT 2 : - • . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Tl[;AJD Receipt Number: 174306 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009 -00336 Branch Circuits wo /Purchase Service or 2200000 -43103 r% $53.50 Feeder ELC2009 -00336 12% State Surcharge - Electrical 1003100 -24001 -- $6.42 Total: _ (7 $59.92 „,:f7 = :• PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $59.92 Payor: Tyler Combs Total Payments: $59.92 Balance Due: $0.00 • • Page 1 of 1 7 11 ° Community Development r 1 �; n IZ n Request for Permit Action =,; ; _ _', ; - -. ji ' All_ i. /UU`i TO: CITY OF TIGARD C i l `q OF Building Division Services Coordinator i l �a f �`� t C} 13125 SW Hall Blvd., Tigard, OR 97223 ". lr.. i t� {,, r }�� /f �� Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov FROM: le5 Owner W Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) Tyf( CoMh Mailing Address: loos' SW INti1pstst C 1 City/State /Zip: l i 41 D i 61 & 9 77 2 Phone No.: . PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( El CANCEL PERMIT APPLICATION. N . REFUND PERMIT FEES (attach receipt, if available). INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: E L L 2 - 003 6 (C l (2- OO ( 1 . 003 3 (c ) Site Address or Parcel #: /5 l3C4 otf , i f i boa `7'1 ,) ; ; 6' j f/‘4°.:— Project Name: Subdivision Name: Lot #: EXPLANATION: ii ,4 VQ0C4 f4 D�/Ot e.G� -- T , ►'Keg /" J Signature: 7 ) 4 rh Date: 4/A / Print Name: f W (a Fibs Refund Policy 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. (7jlnot more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Re 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 Admire: Date B Rte to Bld_ Admin: Date - //A5M B "jj; Refund Processed: Date 7 // Q By r !4T Invoice Processed: Date By Permit Canceled: Date 9 // el By yi'r -- Parcel Tag Added: Date By Receipt # Date Method Amount 8 I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07 CITY OF TIGARD RECEIPT p III g . 13 125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD A i r &'d1 /6 Receipt Number: 175176 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2009 - 00337 $ - 64 . 96 Total: $ -64.96 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DHOWSE 09/11/2009 $ -64.96 Payor: Tyler Combs Total Payments: $ - 64.96 Balance Due: $64.96 Page 1 of 1 IN f; CITY OF TIGARD RECEIPT st 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 € 9+A,[l) Receipt Number: 174308 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 Lavatories 2300000 -43101 - $16.60 PLM2009 -00183 Water Closet 2300000 -43101 $16.60' PLM2009 -00183 12% State Surcharge - Plumbing 1003100 -24001 $8.70 PLM2009 -00183 Minimum Fee Adjustment - Plumbing 2300000 -43101 $39.30:-' Total: $81.20 PAYMENT METHOD . CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $81.20 Payor: Tyler Combs Total Payments: $81.20 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD RECEIPT i l l ill It : 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Tr GARI) 6 0C-7 fir` Receipt Number: 174307 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2009 -00337 Single Duct Exhaust (Bathrooms, Toilet, 2300000 -43102 r •,. $6.80 Utility Rooms) ` MEC2009 -00337 12% State Surcharge - Mechanical 1003100 -24001 $8.70 MEC2009 -00337 Minimum Fee Adjustment - Mechanical 2300000 -43102 $65.70'' Total: ^ • $81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $81.20 Payor: Tyler Combs Total Payments: $81.20 Balance Due: $0.00 • Page 1 of 1 I Community Development _ "I l(i� \IZD Request for Permit Action -ill; 4'• zoos TO: CITY OF TIGARD '�'r ii ! M : .3I 'S''` Building Division Services Coordinator `', tl - . il' \ "`' � = E „.,... 1, 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: tl Owner Vt. Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) 7 I,,, Gooks Mailing Address: 2D/ Q �/1/l r1 _ 8 S k/ City /State /Zip: I Va ( q ' / /1 O,e 97062 Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): ❑ CANCEL PERMIT APPLICATION. E .. REFUND PERMIT FEES (attach receipt, if available). INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ME C200q - 00337 Site Address or Parcel #: x/513 ( .40 '6 0o A. :i , 5i.:. 4 77 — d ` Project Name: Subdivision Name: Lot #: EXPLANATION: wlk V t0 f(�5c.7 Signature: 60/10-1, Date: 7/if/el Print Name: 7 /Nr (co of j s Refund Policy 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 Sys Admin: Date • By Rte to Bldg Admin: Date £ /0'‘;` By - Refund Processed: Date , ea By , " Invoice Processed: Date By Permit Canceled: Date ,�;; By Z/— Parcel Tag Added: Date - By Receipt # Date • / Method Amount $ • I:\ Building \Forms \RegPemutAction.doc Rev 07/26/07 1,111 CITY OF TIGARD RECEIPT q 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 175178 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 $ -64.96 Total: $ -64.96 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DROWSE 09/11/2009 $ - 64.96 Payor: Tyler Combs Total Payments: $ -64.96 Balance Due: $64.96 Page 1 of 1 III CITY OF TIGARD RECEIPT i " :: 13 125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TF (�ARO Receipt Number: 174308 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 Lavatories 2300000 -43101 - $16.60 PLM2009 -00183 Water Closet 2300000 -43101 --.')c2 J $16.60-: PLM2009 -00183 12% State Surcharge - Plumbing 1003100 -24001 ;: `••' ;, : - $8.70 PLM2009 -00183 Minimum Fee Adjustment - Plumbing 2300000 -43101 $39.304-• Total: :: L! $81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $81.20 Payor: Tyler Combs Total Payments: $81.20 Balance Due: $0.00 • • • Page 1 of 1