Permit Support Document Community Development V 0 1 0
TIGARD Request for Permit Action � 7/62--
TO: CITY OF TIGARD
Building Division Services Coordinator
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.
❑ 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 #: BUP2012 -00181
Site Address or Parcel #: 7045 SW Ventura Dr
Project Name: Kelly
Subdivision Name: Lot #:
EXPLANATION: Created incorrect BUP case - should have been an MST Please transfer
funds /payment over to MST2012- 00246. Thank you
Signature: Date: 9/26/12
Shirley Treat
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b) not more than 80 %% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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" /o of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than 80% cif 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 f a 7 /.. By 1 747
Refund Processed: Date P 026//P- By Invoice Processed: Date By
Permit Canceled: Date a 7 / / By , rte r Parcel Tag Added: Date By
Receipt # Date / Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07
RECEIVED q/a;P1fy a — QM- /
� e
A 1 ( 9 1 - 0001
.-� C126r2y �� �� Building Permit Application 172
g PP
v' % _' 1 grakYtingtOW 1y Phone: 503- 846 -3470, Fax: 503- 846 -3993, Inspection Request: 503 -846 -3699
BUS c.tG D1135.R.Nst AV, Suite 350, MS 12, Hillsboro, OR 97124 www.co.was h ington.or.us
. Land Use Approval: Project # Permit #
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
) kkddition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
13 1- and 2-family dwelling Valuation q 000
y g ❑ Commercial/industrial
Number. of bedrooms:
❑ Accessory building ❑ Multi- family
Number of bathrooms:
JOB SITE INFORMATION AND LOCATION
Total number of floors:
Job site address: 70 L S 5;.) V aIrA. 0/
New dwelling area: square feet
City/Statc/ZJP: 'r'1. c a -d C' no.: " R Project name: 91 L7 3
t. f es e Garage/carport area: square feet
SuitefbldgJap
Cross street/directions to job site: Covered porch area: square feet
Deck area: I 4 4 square feet
Other structure area: square feet
Plan No. Reissue: Yes MI No
Subdivision: Lot no.: REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Permit fees' are based on the value of the work performed.
Tae map/'parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK
work indicated on this application.
ktk f � 662._ a cto -e_Q- en'tl".e- 1Oc c k. E-C- t.tk [A I' r.t.20a . Valuation
Existing building area: square feet
[fir PROPERTY OWNER I ❑ TENANT New building area square feet
Name: Max- n F_o_l\ , Number of stories:
Address: 70c St,,) U e,^-6ureL Q.- Type of construction:
City /State/ZIP: TVA e.),‘ /L c0 t2 cf 7 7-Z3 Occupancy groups:
Phone: (507) - a.( 4 - 3025 Fax: ( ) Existing:
13 APPUCANT ❑ CONTACT PERSON New:
Business name: N („) P-p Cp ere c (L L L (.... NOTICE
Contact name: Q2,ec e_ m_GtcIrsory.N All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Address: (O 3 > S!,-) 71 I r "- under ORS 701 and may be required to be licensed in the
City/State/ZIP: - ,r d 0 2 et 7 z z 3 jurisdiction in which work is being performed. If the
applicant is exempt from licensing, the following reasons
Phone: (7v3) 2,-.0 2 I t t 0 I Fax:: (1 ) 2 1 3- 6 Zo Z apply:
E -mail: fZ,e_ e....,..4,..; �C✓r c2_Dec.$:. r►
CONTRACTOR
Business name: 1,3- p_ de _ /1_,_ L BUILDING PERMIT FEES*
Address: i o3,5r) 56-.) '7 l rr A- Please refer to fte schedule
City/State/ZIP: --1 ��t.-1 C� On_ c 7Z23 Fees due upon application S
Phone: (Sp 3 Z Z Z— 1 1 0 I Fax: (S 01 3) AZ. ) 3 - 6 2.0 Z Amount received S
CO3 lie.: 1 3 6 L( 2 T i t : (13 Date received:
Engineer. '5 k LK t v.�r'r l.,.o Architect
Address: `as7 S 2, c --1- Address: This permit application expires if a permit is
not obtained within 180 days after it has
Phone:(3D ) 6 -Io -G g og Phone:( ) been accepted as complete.
Email: ve.-Jc1,, A . Lpi,,1 . _ Email- a
Fee methodology set by Tri-Comity Buildin
Authorized /
Industry Service Board
signature:
Print name: 5' 6 I .. 1 r r, '‘• Date: ' - AL{— 1 Z 440 (8/06/COM/WEB)