Permit VO
City of Tigard • COMMUNITY DEVELOPMENT DE ARTMENT
Request Permit Action Re
q ct on ._UN 2 6 2017
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or..gov .. .,
•
TO: CITY OF TIGARD
Building Division Services Supervisor
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) ( ' lr Cy pc) i . 0O Itit 043 i f (11.4..426 /
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Mailing Address: j(07,5
City/State /Zip: t (G eL O
Phone No.: — G3 7 _313
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CON P'.` 'UR O _ (do not cancel permit).
;
Permit #: s'/ 7 6 000/9 • 7 i , j ,
Site Address or Par. -1 #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION:
Signature: Date: a 20I Z- .
Print Name: Ayt 5 l2 , Gc.J 1 ` (So/
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 B Rte to Bld : Admin: Date "=
Refund Processed: Date iv4011.11 B „, m Invoice Processed: Date /�7` �e- `e '// f
Permit Canceled: Date 7AGrAni B � �, Parcel Ta • Added: Date B
Receipt # Date Method Amount $
I: \Building \Forms \RegPermitAction.doc Rev 05/25/2012
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e Permit Application S 0 7//e/42_,gyri---
Commercial FOR OFFICE USE ONLY
Received c
City of Tigard � O lq /v�,/ Permit No.: �C,L '..,F1 �.jl,
Ill Date /B} : `" 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review
Ill Phone: Permit: /
Phone: 503.639.4171 Fax: 503.5 Date /Bv: - _ _
I' I G A R D Inspection Line: 503.639 ®0� Date Ready /By: Juris: n See Page 2 for
Internet: www.tigard- or.gov Notified /Method: / .L Supplemental Information
a \ O
TYPE OF WORK ISC .14 REQUIRED DATA: 1- AND 2- FAMILY DWELLING
▪ ® New construction ❑_ yG V Permit fees* are based on the value of the work performed.
```�
`, Indicate the value (rounded to the nearest dollar) of all
• ❑ Addition/alteration /replacement MA': equipment, materials, labor, overhead, and the profit for the
J
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ I- and 2- family dwelling ® Commercial /industrial Valuation: $
❑ Accessory building ❑ Multi- family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 11075 SW GAARDE ST New dwelling area: square feet
City /State /ZIP: Tigard /Or/97224 Garage /carport area: square feet
Suite /bldg. /apt. no.: Project name: Grace Point Community Chu Covered porch area: square feet
Cross street/directions to job site: SW 110 and SW Gaarde St. Deck area: square feet
Other structure area: square feet
REQUIRED DATA: COMMERCIAL - USE CHECKLIST
Subdivision: Lot no.: 1100 Permit fees* are based on the value of the work performed.
Tax map /parcel no.: r477852 Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK work indic ed on this ap 'cation.
Addition of new sanctuary, lobby, classrooms and multipurpose space. Val uatioV $
Existing building area: square feet
New building area: 24247 square feet
® PROPERTY OWNER ❑ TENANT Number of stories: 2
Name: Grace Point Community Church - Jim Wilson rep. Type of construction: 5b
Address: 11075 SW Gaarde St Occupancy groups:
City/State /ZIP: Tigard, Or 97224
Existing: A3
Phone: (503 )639 3913 Fax: ( ) New: A3
® APPLICANT ® CONTACT PERSON NOTICE
Business name: Mark Siemieniec Architecture All contractors and subcontractors are required to be
Contact name: Mark Siemieniec licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: 7575 SW 91 Ave jurisdiction in which work is being performed. If the
City /State /ZIP: Portland , Or 97223 applicant is exempt from licensing, the following reasons
apply:
Phone: (503 ) 245 4163 Fax: : (503 ) 245 4163
E - mail: mas@ ms- arch.com
CONTRACTOR
Business name: to be determined BUILDING PERM1 FEES*
Address: (Please refer to fee schedule)
Structural plan review fee (or deposit): IRCP ( OH 37
City /State /ZIP:
FLS plan review fee (if applicable): (91 G!
Phone: ( ) • )
CCB lie.: `r
/ Total fees due u a / a W. ,}6 Cr
���-r Amount received:
Authorized signature:
This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name: Mark S',•� ieniec Date: 08/19/2008 * Fee methodology set by Tri- County Building Industry
Service Board.
I: \Building \Permits \BUP -COM PennitApp.doc 2/23/07 440- 4613T(I1 /02 /COM /WEB)