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Permit VOID o 1 o z�a Community Development TIGARD Request for Permit Action RECEIVED � FEB 2 1 2012 TO: CITY OF TIGARD CITY OF TIGARD Building Division Services Supervisor BUILDING DIVISION 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.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( CANCEL PERMIT APPLICATION. El REFUND PERMIT FEES (attach copy of original receipt). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). El REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ()o a �a Site Address or Parcel #: /Y a t Go t 14) /)-LA J rG C'Pfs! &y Project Name: A-O 10 V t Q GJ Subdivision Name: Pi L. Pt s3 V i E Lc.) Lot #: EXPLANATION• ��v i H i i C�� E L o PM E,01 c7 1 - 0 r Tv iJ r.)� t 1 r - R - 10 E5T: Y w, -- u H , - ft t APPL /m . Signature: Q/ Date: 0 R i/ 2-- Print Name: — DiA/! it 51. 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 2-4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to S s Admin: Date , HI B _ Rte to Bld: Admin: Date o Zmm B Refund Processed: Date A/ B t: i% Invoice Processed: Date By Permit Canceled: Date o 202//,2— By 45 Parcel Tag Added: Date By Receipt # Date Method _ Amount $ 1: \ Building \Forms \ReqPermitAction.doc Rev 04 /26/2011 Plumbing Permit Application , Building Fixtures /�'.2- �� FOR OFFICE USE ONLY City of Tigard Rec e ived 7 i Date/By: 1 1 Permit No.: /p V , If -- _402.1-42 a 13125 SW Hall Blvd., Tigard, OR 97 - ' #� P lan Review 2 . Phone: 503.639.4171 Fax: 503.598.1' 4; E Q\ Date/By: Outer Permit No.: TI G A R D Inspection Line: 503.639.4175 R ate Ready/By: l: ® See Page 2 for Internet: www.tigard or.gov t , A P _ Q ot " e t h od : ens rir-CF Suppleme Information ti..* OF WU) C - J ftS1" \ FEE* SCHEDULE ® New.construction ❑ Demoliti Forspeclal Information use checklist. L Description I Qty. i Ea. I Total ❑ Addition/alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. 'for each utility connection) - ' - - -y; ° : ^ CA!DEGORY -OE :CONSTRIICTIQ' '' `° SFR(1) bath 312.70 ®•1- and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 437.78 SFR (3) bath 50032 ❑ Accessory building ❑ Multi - family Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page2 �` _� s•. r F I "" Site utilities: JOH b, IiVRORMir11UN AI! LO.GA Job site. address: /yh(� ). /VA 6.es f Catch basin or area drain 18.76 ! Dlytvell, leach line, or treacle drain I B:76 City /State/ZIP: Tigard OR 97224 Footing drain (no. linear ft.:, ) Page 2 Suite/bldg. /apt. no.: I Project name: Manufactured home utilities 50.03 Cross street/directions to job site: Manholes .18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: __) Page 2 Water service (no. linear ft.: Paget Subdivision: I Lot no.: Fixture or item: Tax map /parcel no.: Backflow preventer 1 31.27 r - - _ - . .. ... ,z. x .__., -_ Backwater valve 12.51 - DE5GRIPPIQN OF WpnR Clothes washer 25.02 de -f7 .) Dishwasher 25.02 Drinking fountain 25.02 • Ejectors/sump 25.02 Expansion tank 1251 ®' orxm OWNER : " I 0'114 �v Fixture/sewer cop 25.02 Name: West Hills Development Floor drain/floor sink/hub 25 :02 Address: 735 SW 158 Ave Garbage disposal 25.02 City /State/ZIP: Beaverton OR 97006 Hose bib 25.02 Phone: (503)641-7342 Fax:(503)641 -7661 Ice maker 12.51 ' ; ' 2} '.P191CA1V1' ' 0 aorirrnc�lr ii io i4 interceptor /grease trap 25.02 Business name: - ^ West Hills Development Medical gas (value: $ ) Page'? Primer 12.51 Contact iutine: Angie Cook • Roof drain (commercial) 12.51 ,, Address: 735 SW 158'" Ave. - Sink/basin/lavatory .25.02 City /State/ZIP: Beaverton OR 97006 Solar units (potable water) 62.54 Phone: (503) 641 -7342 Fax: : (503) 641 -7661 Tub/shower /showerpan .12.51 Urinal 25.02 E -mail: acook@arborhomes.com Water closet 25.0 C0191CAAGI� © .. - - -- - - - Water heater 37.52 Business name: Trademark Landscape Water piping/DWV 56.29 Address: 19088 S. Redland Rd. Other. 25.02 City /State/ZIP: Oregon City, OR 97045 Subtotal Phone: (503) 631 -3893 Fax: (503) 631 -4737 Minimum permit fee: $72.50 -2,2 6 Plan review (25% of permit fee) CCB Lic.: 11353 Plumbing Lic. no.: State surcharge (12% of permit fee) 7 Authorized signature: 4010 TOTAL PERMIT FEE k/. f) Print name: Steve Ellis Date: - 7 f q // This permit application expires if n permit is not obtained within ISO days after It has been accepted as complete. "Fee methodology set by Tri County Building Industry•, Service Board. 1. t0uildingWerminOPLAW- PenniiApp.doc 10/01/09 440 -1616T(10102/COMAYEI)