Permit A Building Division
/4.,1,4 Request for Permit Action or Refund
City of Tigard RED v
TO: CITY OF TIGARD, BUILDING OFFICIAL
13125 SW Hall Blvd., Tigard, OR 97223 2006
Phone: 503.639.4171 Fax: 503.598.1960
CITY U! itiutilkif
FROM: ❑ Owner ❑ Applicant ® Contractor zligrpip r ' aff j 1IlrCTOT
(check one)
Name:
0 1 D (Business or Individual)
Mailing Address:
C' /State /Zip:
- C/0 6 Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: SWR2006 -00074
Site Address or Parcel #: 15755 SW Sequoia Pkwy #100
Project Name: Bridgeport MRI
Subdivision Name: Lot #:
EXPLANATION: Contractor added 2 capped sinks to original permit making balance
of sewer (0). Please also remove sewer talley sheet for this project.
Signature: - - Date: 5/12/06
Dodie Rossetti
Print Name:
Refund Policy
1. The Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payee in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to Sys Adtnin: Dates) Vt By'jr. 4 Rte to Bldg Admin: Date By
• Refund Processed: Date � � B Invoice Processed: Date By
Permit Canceled: Date4» /d Ca B cel Tag Added: Date By
Receipt # Date Method Amount $
I:\Building\Forms\ ReqPermitAction 09- 19- 05.doc dial 7 /- // _
A Accumulative Sewer Tally Parcel # 2S112DD- 0.1601
Tenant Name: Bridgeport MRI This SWRt SWR2006 -00074
Site Address: 15755 SW Sequoia parkway This PLM# PLM2006 -00147
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added tota ' total
count off #s count # value values
Baptisery /Font 4 0 0 0 ii 1 0 0
Bath - Tub /Shower 4 0 0 0/', 0 0
- Jacuzzi/Whirlpool 4 0 0 .� , 0 0
Car Wash - Each Stall 6 1 0 Z - 0 ' 0 0 0
- Drive through 16 4 0 t" 0 l 20 0 0
Cuspidor/Water Aspirator 1 0 0 t ' 0 0
Dishwasher Commercial 4 0 , 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 . 0 0 0
Floor Drain /Sink - 2 inch 2 0 0�' ` 0 0 0
4
3 inch 5 0 0 ,f' 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 k 0 0 0 0
- Commercial (to 5 HP) 32 0 \ 0 0 0 0
- Industrial (over 5 HP) 42 0 { (..f' 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 \,, 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 / Ir` 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0
Sink - Bar /Lavatory 2 e ` 0 0 0 0
- Bradley 5 •. 0 0 0 0 0
- Commercial 3 ( f ; 0 2 6 0 -2 -6
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 X 0 ,,,,; 0 0 0 0
Urinal 6 0 z ' 0 0 0 0
mow,, ; ,.,,,:..0 ��
Previous EDU Count . ? & 0 0
Capped EDU Credit 0
...............
TOTALS 0 0 2 6 1 6 -1 0
Current Fixture Value 0 divided by 16 = 0.0 Current EDU 1 EDU = $ 2,600
Previous Fixture VaI 0 divided by 16 = 0.0 Previous EDU
Change 0 divided by 16 = 0.0 over (under) $ -
Enter EDU Change Here „„;,,,
Notes: /
Authorized Name /Signature: Dodie Rossetti Date: 5/12/2006
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/05