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Permit CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit #: PLM2009 -00144 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 06/11/2009 Parcel: 2S112CB01900 Jurisdiction: Tigard Site address: 8056 SW ASHFO.RD_SS Subdivision: ASHFORD OAKS NO. 2 Lot: 33 Project: Jacobs Project Description: Install (1) lay, (1) sink, and (1) d /w. Owner: FEES JACOBS, ROLAND L & KIMBERLY M Quantity Description Date Amount 8056 SW ASHFORD ST TIGARD, OR 97224 1 ea Dishwasher 06/11/2009 $16.60 PHONE: 1 ea Sink 06/11/2009 $16.60 1 ea Lavatories 06/11/2009 $16.60 1 12% State Surcharge - 06/11/2009 $8.70 Contractor: Plumbing MILWAUKIE PLUMBING CO 23 ea Minimum Fee Adjustment - 06/11/2009 $22.70 PO BOX 393 Plumbing CLACKAMAS, OR 97015 PHONE: 503 - 655 -9161 FAX: 503 - 655 -1726 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: ' ( I Permittee Signature: /1 n 511 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. • Pluinbini Permit ApnLicad4 ECFIVFO N , r ;rt # v ry , .'ry{' kt w r1 na 1^- ^ 7 ! v k � a �S 'Lr a i r}) u Building Fixtures JUN 10 2OO9 j" " ' ' , ` (� r ` � ��1 OK t I I( ')I I • lw) I t�l l t , 't { l " ,1� (21 sN' 14 4 "t ,, City of Tigard PermitNo,::I 1a'/ ii • • V a 131 SW Hall Blvd,, Tigard, OR 972 ., gar, OF T IGA RD ,c, I g Plan Review Phone; 503.639.4171 Fax: 503.598. 1' Uther Permit No.: Inspection Line: 503.639.4175 RU DING DIVISION Date /B : ( ri' ,tt'I;1 Date Ready/By: la Page 2 far Internet; www.tigatd-or,gov Notified/Method: SupplementalInformatioa � . : . .. t r ' r h Sf\YiA'F iii ,er • W1)" n" flt� '$1�i�7�/.l.'�:�': }�i.AX:L1r • �' �:'1\ � Y�' ' � � � ., r . . \ r�"�7,y` -- �'+;, § §' § ?klv.W�,''r6 } } } },�� iipyl §Y§}F§"n'R+1Jn ^AV7Mld to AS / i \ 1 ¢ n:(', � �770;. � ;+tx. }{z�rr;... \ � �t}l {� rt':,{: i k� , s ' { y�� j g p p ? g� , �V y :,i,' §� ?,p�� r Ar r + �ityg'��{'nI �' \ :�{� }�Y y AV. t igiA 11 "H, .%.k u Y� �vv1+' Nt o 4i*i i' 7h !: ^ it , im Iiip i,' �� i''.w(tignI Jtr1 ..:kltt .�.:J�6:�Y `mIM�6f9co. t ) "•:11 +SIf �, 1 ,, t r '0, w.,.. A d i t OV+ino Y am . �St?sv�lA'n�• RI. © New construction ❑ Demolition For special Information use checklist. Description I Qty. I En, I Total r 4 Addition/alteration /replacement 0 Other New 1- 2- family dwellings (includes 100 it for each utility connection) �e ',h' yygvS C3y0..f y; Yry' i 0.. 10.: tr7t ::k�:i4u�.•.n,g.,§;:,:j•PitiMI S§" U\ WRfiiY RP ?¢y �1 {\ \ ' ° "'' u §, MM' ct, S ut 249.20 8i "� § 4,/kag Y , qq dt'. ; 1.4.4.•4,-114„,,A ,1 �r t Nq,... .�'. Vyl,., i e •(. p .ni /t 9 .!: i ' ll8 71 v f .• i4Cti.V 4 YkA4JA bl 0 1- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath 350.00 CI Accessory building ❑ Multi- Palnily SFR (3) bath 399.00 El Master builder Each additional bath/kitchen 45.00 ❑ o ther: v wv i• s,' r -/- v + ,.•,• Firc sprinkler ( sq. ft.) Page 2 AP a rf „ 1 7 . 'sa.ti,'no-YI , (ri�lr 4.4 s�Iin3V! ' kl I .isi A : to ,i 1 , , t} t , ��,,,:��+��! � '� � , �i§}d4«ai ;a�tv�kmmnul ;�r„rrint:o<rcvtv.>G.rks +r�ss riwfanJl >avr� eYauiA'u�lufb,�ld,ad�` & i Site utilities Job site address; as) . p St „,„ a r(t. )A t - ' Catch basin or area drain 16.60 City /Slate/ZIP: "f l r '{D ,1_;_\123-__ Dtywcll, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: Project name: 1 - Footing drain (no. linear ft.; _) Pagc 2 1��n `I a`d f I._ Manufaetured home utilities 110.00 Cross street/directions to job site; Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: _) Page 2 Stine sewer (no. linear IL: Page 2 Subdivision: I Lot no.: Water service (no. linear ft.; ) Page 2 Fixture or item Tax map/parcel no.: Absorption valve 16.60 �a , � k tat��}S�Bt ^ +1 ' k4t1 , �' ln' td g d,. J"b'` v v; A ' ' '''Cd h..1 N `llR r '! V ' I m :W.A M^ 1 r fI ; $a c - o w preventer Page 2 a 1, W - l , 1 WV tsv\ ' )[ ` • - I$IJ 4 Backwater valve I6.60 1 L' In t • , 1 Clothes washer 16.60 - - .,, to , Dishwasher , 16.60 ' r wow R r r t 4. a l{' ^ r , i 8{ ! • ' w iA'a Csy urrix u , rip Drinking fUuntarn 16.60 Auzl ;i tioa ,ni2tolt'tiput:ox ? A . ° :';.4'.. ( Kitkl n Y w� t tans §r it i E octors / sump 16.60 Nye Expansion Lank 16.60 Address: Fixture/sewer cap 16.60 City /State /ZIP: Floor drain/floor sink/hub 16.60 Phone: ( ) Fax: ( ) Oaibage disposal 16,6(1 r r a u4 • me an i (r fi'k' 050b / {��+ x ^.x mrn i aa w nrr 3. �t �" 7A� r +r• h• H r 16.60 Wµµ h x\ r r at fir! s 9 V '.r. E i I : M SAM: �:e d .tlrr�r,iMitC I k «rev � ' , .(W 4�bb:' INKVtu T. 40, 04a+t t Witan, A I ce maker 16.60 Business name; Interceptor /$trace trap 16.60 Contact name: Medical gas (value: $ _) Page 2 Address: Primer 16.60 City/State /ZIP: Roof drain (commercial) 16.60 Phone: ( ) I Fax:: ( ) Sink/basin/lavatory 2- 16.60 Tub /shower /shower pan 16.60 E -mail: IL, fir" ( • - . IT) Urinal 16.60 � )hl v Ss �zw•M nttt ei ,s n h e or: F . "Aa ,z; t r kt�"�t: wuaalaa;�s`•'wtm'i t' lY .(tS +kl Waterolosel X 16.60 Business name: fy)1? - 7)\ \,0 I �( \ k _ Water heater 16.60 Address: VP ` O• • "� Other. f City/State/ZIP: �1aC a r q Subtotal ,IL's minimum permit fa; $72.50 Fax: Residential backtlow minimum permit tee: $36.25 (��)(�� tllol (� - ►gal P Phone: �� CCB Lie.: Plumbing Lie. no,: I Plan review (25% ofpernlit tcc) _ - • State surehargc (12% of permit fee) ,1 J Authorized signature: TOTAL PERMIT FF,F �) . Print name: • , Date: i ram This permit application expires If a permit Is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by '16-County Building Industry Service Board. 19IIuildine 1Pirmil:PLS4F- Po\nrtApp I2l.7rOL 440- 1616T(I0'02 Z d 88800000SL 'oN /bb : 0l ' 1S /St :0l 800Z 01 Nnr (03M) HOad . . ( FROM (FRI)AUG 21 2009 13: 27/ST. 13: 23/No.7500000083 P 1 11 .4 ' ECEIVED -1 Community Development AUG 2 1 2009 a ; . r , Request for Permit Action CITY OF TIGARD 1JI.LDINO DIVISION TO: CITY OF TIGARD Building Divisions Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fait: 503.598.1960 www, tigaxd- or.gov FROM: ❑ Owner ❑ Applicant [] Contractor (cheek nut) ❑ City Staff REFUND OR Name: • INVOICE TO: (BusintN6 ox r nd ; vid „an . / / ,/,/ / /. / /71 Mailing Addxc ; » 13 City /State /Zip; //�� c' Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL PERMIT APPLICATION, 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). Petlnit #: _tatill_g_ p l Site Address or Parcel A; few die alifi dgi, Project Name: , / /_/ /.ti., 1 / Subdivision Name: Lot #: - EXPLANATION: ns r - ac_o ?-- o�a� _ Signature: % / 1 Date: 7 - j / • pq / Print Name: 41 / .1' 1. The Director or Building Official may authorize the refund of a) any fee which was erroneously pt d of collected. b) not more than Pte /o of the land use application fa when an a,piieat on is withdrawn as earkeelcd before any review effett sty been expended. e) not more than BM- of the land use application fee for issued penoim d) not more than 81,"i of th building phut review foe when to npplkatinm it canceled before any plan review effort has been expended. c) nor more than 1110% nF the buildin p<rr ut fee tot • i s sied permits prior re cry in peu;on request 2. Refunds will be returned to the original Pxyer in the tame method in which payment was received. please allow 1 -2 weeks for procosing cfunde. I t )I; ()T 1..I .. t "t \I \ Roe to 5 • s Admin: Dart T rinfra Rte to Bt.. Admin Date - ry EM - �•, Refund Processed: Date 13 Invoice Processed: Date g Permit Canceled: Date 45 i9 A. i ills . Date Ii Reed . t # 7: Date 1 Method C C._ Amount T tmluitding \ \RecPccrrdtAetinn.d • R v e# 20/07 -- 11 q City of Tigard TIGARD 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: MP Plumbing Co., Inc. DATE: 9/22/09 P.O. Box 393 Clackamas, OR 97015 REQUESTED BY: Dianna Howse Attn: Tami George TRANSACTION INFORMATION: Receipt #: 173949 Case #: PLM2009 -00144 Date: 6/11/09 Address /Parcel: 8056 SW Ashford St. Pay Method: CreditCard Project Name: Jacobs EXPLANATION: Permit created in error as work was completed under MST2009- 00123. Refund 100% of permit fees. e2'}'. .d'hi :, -ry "'• - 'M��'`4...^..�y,7f3= ..':b,s- _ "�- .:i,,..�t,- - :, ii +;.�s+t• ;?�. .,, &r,.. „'” 7 '�F:� �„YV ^. ",_4'i�- ti"= 4r�'.�`: ; ...n. eiwS �- .v ^" ae h�itL..:r, .. *x`� , RFSs=r -' .'S' ..'.'� -,. ,.,�. ?t� +,ti. +ss�'...:.v�._'T x . ,, .°„�z.. '• �`�i� �REFU N�D�INFOR=IVIAT.ION. .`t,� ..�:., ,.�s�:�,k: , ,�.x- , .?';t, �;.� ��:.�, „ -;� ��.a .s.�s, _.�.._ �. - _ .. .n ✓,�.1.I= �9w�t..l`� „�.�. ;°;b;"-e;� >i';. ?s�. -s: „«�i�e��'���._�� -.._ :.3- .� „.�,F+_v,a.�„C'r`..: .sgn,�5�•.,.kY. -. ,..z.�:�; i 4� ,.4.4. f... .tE3°. -.� .+t.. yillc^. '3.., - -X:. .. �,}'t .:; },*.�'}; �:..`L�k„- x ia�}�Fr ;.. ..l'".'�:.N. �F4�;: s °a`'`'+tiS' i1%.t at zz2:z'�",,:;2 ',.y...ig`.,z*! . ”. ^ +; Fea escrt tion�;F „ „rom�Rg - t •e�,��. Ei y . ' {' - .Revenue =AccO itirNo.kr . #N, ` g li efundaw ? pd - c ,�. x u., - �.. ; ' . ,.�., rs...t ?L`:�+r. . f'' 9 � 6 . i ' i , .r }. ..k .. c.. i -_ x,• C .; , r;3 � _ ..,� .; *:v , }�.�,. � �' . x:�»'. *:y,2q +rr � X ; - ”- ..x.[.:.�ts ?> :,1'.` -? °S4 .�, �.: - a:e , #:� ". ; �Xam - le: ' II D `P - �. , : , .., (EXam "le kn245= 0 0=4. 000 , x. Amount�< �re_..._..._P.. ,��. - � .��.,- •_..�- _._�.�`.� -._.., �.Y<..� �:. �, �€ �.2��� %�;�`F��,.....P._,�r.4,ii <,.,..._ , n. rh .u..- _.,�.�..,,.....,.�, -r._a. ....- K..x- >'�',= '.�;,��' "F3�"� _ _.,_....n..�. ,��'• .P Plumbing Permit Fees 245 - 0000 - 431000 $72.50 12% State Surcharge 100 - 0000 - 207020 8.70 TOTAL REFUND: $81.20 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager q i f - 3' A 's.) If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board „ gtAeff t n ,PVAV ig :MSY5TEMiADMyINI-SMPON USRONLY, Refund Request Reviewed: Date: ,Y :..2> ,, ' By: y . Case Refund Processed: Date: ' ,, G 2 By: ,455:44 r ` I: ABuilding \ Refunds \RefundRequessi.doc 04/13/09 • City of Tigard, Oregon ° 13125 SW Hall Blvd. ° Tigard, OR 97223 II I 'I L\ '\ r September 24, 2009 MP Plumbing Co. P.O. Box 393 Clackamas, OR 97015 Attn: Tami George Re: Permit No. PLM2009 -00144 Dear Ms. George: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 8056 SW Ashford St. Project Name: Jacobs Job No.: N/A Refund: p Check # in the amount of $ . ® Credit card "return" receipt in the amount of $81.20. ❑ Trust account "deposit" receipt in the amount of $ . Notes: Permit created in error as work was completed under MST2009- 00123. 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 li City of Tigard TIGARD 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: MP Plumbing Co., Inc. DATE: 9/22/09 P.O. Box 393 Clackamas, OR 97015 REQUESTED BY: Dianna Howse Attn: Tami George TRANSACTION INFORMATION: Receipt #: 173949 Case #: PLM2009 -00144 Date: 6/11/09 Address /Parcel: 8056 SW Ashford St. Pay Method: CreditCard Project Name: Jacobs EXPLANATION: Permit created in error as work was completed under MST2009- 00123. Refund 100% of permit fees. REFUND INFORMATION:. Fee Description From Receipt Revenue Account No • Refund , . `Eicample: ':(BUILD1 Permit Fee . ' Example:. 245- 0000 - 432000 $ Amount Plumbing Permit Fees 245- 0000 - 431000 $72.50 12% State Surcharge 100 - 0000 - 207020 8.70 TOTAL REFUND: $81.20 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager / 1 11 110a 1 If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board . ' '. FOR ACCELASYSTEM ADMINISTRATION USE ONLY . • Refund Request Reviewed: Date: %�..2 /c ? By: ✓� Case Refund Processed: _ Date: 9,42,7e ,9 By: I: \Building\ Refunds \ RefundRequest.doc 04/13/09 CITY OF TIGARD RECEIPT p a . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD / 1 ril Receipt Number: 175328 - 09/24/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 - 00144 $ - 81.20 Total: $.81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 011253 DHOWSE 09/24/2009 $ -81.20 Payor: Milwaukie Plumbing Co. Total Payments: $-81.20 Balance Due: $81.20 Page 1 of 1 , CITY OF TIGARD RECEIPT ! .. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 173949 - 06/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00144 Dishwasher 245 - 0000 - 431000 $0.00 PLM2009 -00144 Sink 245- 0000 - 431000 $0.00 PLM2009 -00144 Lavatories 245 - 0000 - 431000 $0.00 PLM2009 -00144 12% State Surcharge - Plumbing 100 - 0000 - 207020 $0.00 PLM2009 -00144 Minimum Fee Adjustment - Plumbing 245 - 0000 - 431000 $0.00 Total: $0.00 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 011253 LSELLERS 06/11/2009 $81.20 Payor: MILWAUKIE PLUMBING CO Total Payments: $81.20 Balance Due: $81.20 • Page 1 of 1 PROM (FRI)AUG 21 2008 13: 27/ST.13: 23/Ho.7500000083 P 2 • u CITY OF TIGARD RECEIPT - 1 g 13125 SW Hall Blvd., Tigard OR 97223 ;i 503.639.4171 1 (I;AI1 !) Receipt Number: 173949 - 06/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009-00144 Dishwasher 245-0000-431000 516.80 PLM2009 -00144 Sink 245 -0000- 431000 $16.60 PLM2009 -00144 Minimum Fee Adjustment - Plumbing 245-0000-431000 822.70 PLM2009 -00144 12% State Surcharge - Plumbing 100-0000-207020 $8.70 PLM2009-00144 Lavatories 245-0000 - 431000 $16.60 Total: $81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 011253 LSELLERS 06/11 /2009 $81.20 Payer: MILWAUKIE PLUMBING CO Total Payments: $81.20 Balance Due: $0.00 • • • CITY OF 1I602 PERMITS 13125 SA HALL BLUR TI8005, M. 97123 TERMINAL I D.t BB17348888888313865881 IERCNANT I 8853138558 IC PCARD . t SALE • RECORD it 6 INM: SBUB6 DATE: !UH 11, 59 TIlCI 11148 BAICH: 381 ADM 811251 COST iin, i 8885 RUT RE" ( 1 : Z 5 DIGIT ZIP HATCHES, ADDRESS DOES NOT TOTAL 1181.28 I AGREE 10 PAY ABOVE TOTAL AMOUNT ACCORDING TO CARO ISSUER AGREEMENT (MERCHANT AGREEMENT IF CREDIT UOUCIER) Page 1 of 1 CUSTOIER COPY