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Permit City of Tigard, Oregon 13125 SW Hall Blvd. 0 Tigard, OR 97223 • 11 • .{ • September 11, 2009 Tyler Combs 20908 SW Winema Ct. Tualatin, OR 97062 Re: Permit No. ELC2009- 00336, MEC2009- 00337, PLM2009 -00183 Dear Mr. Combs: - The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 10990 SW 79 Ave. Project Name: Combs Job No.: N/A Refund: ® Check #100517 in the amount of $177.86. ❑ Credit card "return" receipt in the amount of $ ❑ Trust account "deposit" receipt in the amount of $ Notes: Per applicant's request as project was cancelled. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I: \Building\ Refunds \Administrat ion \LtrRefund- CancelPerrnit.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • • www.tigard - or.gov • TTY Relay: 503.684.2772 I 1 0-1,1 nt -t CcsVlQ e� citujrxxA y CITY OF TIGARD ELECTRICAL PERMIT COMMUNITY DEVELOPMENT Permit #: ELC2009 -00336 TLGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 07/10/2009 • Parcel: 1S 136CA04600 Jurisdiction: Tigard Site address: 10990 SW 79TH AVE Subdivision: FRIENDLY ACRES Lot: 2 Project: Combs Project Description: Alter (2) branch circuits to change outlets and add lights. Owner: FEES COMBS, TYLER Quantity Description Date Amount 20908 SW WINEMA CT. TUALATIN, OR 97062 2 crt Branch Circuits 07/10/2009 $53.50 wo /Purchase Service or PHONE: 503 - 545 -4177 Feeder 1 ea 12% State Surcharge - 07/10/2009 $6.42 Electrical Contractor: OWNER PHONE: FAX: Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: Total $59.92 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. AD 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: % /� Perm ittee Signature: ��J.JLJ2 - C1VV OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC' Date: LICENSE NO. CaII 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. 71 CIT Y OF TIGARD ELECTRICAL PERMIT 2 ~ ' . - COMMUNITY DEVELOPMENT Permit #: ELC2009 -00336 13125 SW Hall Blvd., Tigard OR 97223 503 .639.4171 Date Issued: 07/10/2009 I . . , Parcel: 1S 136CA04600 Jurisdiction: Tigard Site address: 10990 SW 79TH AVE Subdivision: FRIENDLY ACRES Lot: 2 Project: Combs Project Description: Alter (2) branch circuits to change outlets and add lights. Owner: FEES ROBERTSON, SANDON P AND Quantity Description Date Amount NOYES, PAMELA S, 10990 SW 79TH TIGARD, OR 97223 2 crt Branch Circuits 07/10/2009 $53.50 wo /Purchase Service or PHONE: Feeder 1 ea 12% State Surcharge - 07/10/2009 $6.42 Electrical Contractor: OWNER PHONE: FAX: Type of Use: SF Class of Work: ALT Type of Const: Occupancy Grp: Total $59.92 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 throu 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: 0(ftQ ,AQ/ /� �, Permittee Signature: a—X Q A T P OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale, lease or rent. OWNER'S SIGNATURE Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR. ELEC' Date: LICENSE NO. 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. R ECEI VE r Electrical Permit Application FOR OFFICE USE ONLY El City Received permit No.: it 131 of Tigard SW Hall lvd., Tigard, OR 97223 JUL 10 2009 Plan Resew F te . b®` �' Phone: 503.639.4171 Fax: 503.598.1960 Date/By: Other Permit: in Inspection Line: 503.639.4175 CITY OF TIGARD Date Ready/By: Juris: ® See Page 2 for Internet: www.tigard - or.gov BUILDING DIVISIO Notified/Method: 1 (�� Supplemental Information TYPE OF WORK PLAN REVIEW ❑ New construction ❑ Addition/alteration/replacement Please check all that apply (submit 2 sets of plans w /items checked below): ❑ Service or feeder 400 amps or more ❑ Building over three stories. ❑ Demolition ❑ Other: where the available fault current ❑ Marinas and boatyards. CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑ Floating buildings. less to ground, or exceeds 14,000 ❑ Commercial -use agricultural ❑ 1- and 2- family dwelling ❑ Commercial /industrial ❑ Accessory building amps for all other installations. buildings. ❑ Multi - family ❑ Master builder ❑ Other: ❑ Fire pump. ❑ Installation of 75 KVA or ❑ Emergency system. larger separately derived system. JOB SITE INFORMATION AND LOCATION ❑ Addition of new motor load of ❑ "A ", "E ", "1 -2 ", "1 -3 ", Job no.: Job site address: Q„ r /� 100HP or more. occupancy. I� UV S * - 7 4 TH "" �� ❑Six or more residential units. ❑ Recreational vehicle parks. City /State /ZIP: ! I6- te® zZ ❑ Health -care facilities. ❑ Supply voltage for more than 1 `y'- / ` ❑Hazardous locations. 600 volts nominal. Suite/bldg. /apt. no.: Project name: CO/� 8 S ❑ Service or feeder 600 amps or more. � 4 n -' .� /� t 7V21.. FEE SCHEDULE Cross street/directions to job site: �/ c�- Description 1 Qty. 1 Fee. 1 Total N &4/' TI-/6 H(» 11 6)(17 6)(17 Ur C / f" 0� ZI1 New residential single- or multi-family dwelling unit. Includes attached garage. Subdivision: Lot no.: 1,000 sq. ft. or less 145.15 4 Tax map/parcel no.: Ea. add'l 500 sq. ft. or portion 33.40 1 Limited energy, residential DESCRIPTION OF WORK (with above sq. ft.) 75.00 2 i I Limited energy, multi - family 75.00 2 (h / ©tl - ) G c W l �1 , I,' 1,-/ re (with above sq. ft.) S ervices or feeders installation, alteration, and /or relocation 200 amps or less 80.30 2 4 PROPERTY OWNER ❑ TENANT 201 amps to 400 amps 106.85 2 Name: TyLE /Z CO/143S 401 amps to 600 amps 160.60 2 A 601 amps to 1,000 amps 240.60 2 Address: Z 0 Og SIAJ VA) I N t /'1 A GT. Over 1,000 amps or volts 454.65 2 City/State /ZIP: TvAC — /N 0 g_ 9 - 70 6 2 Temporary services or feeders installation, alteration, and /or relocation Phone: ( 503) S — L(f 77 Fax: ( ) 200 amps or less 66.85 1 Owner installation: This installation is being made on property that I own which is not 201 amps to 400 amps 100.30 2 intended for sale, lease, rent or excha e, according to ORS 447, 449, 670, and 701. 401 amps to 599 amps 133.75 2 � i JU Y l D Branch circuits — new, alteration, or extension, per panel Owner signature: f _ Date: / A. Fee for branch circuits with ❑ AP ICANT ❑ CONTACT PERSON above service or feeder fee, 6.65 2 each branch circuit Business name: B. Fee for branch circuits u A Contact name: without service or feeder fee, 46.85 - (6j �1� 2 first branch circuit Address: Each add'l branch circuit / 6.65 G. 6r 2 Miscellaneous (service or feeder not included) City/State /ZIP: Each manufactured or modular dwelling, service and/or feeder 90.90 2 Phone: ( ) Fax: : ( ) Reconnect only 66.85 2 E -mail: Pump or irrigation circle 53.40 2 CONTRACTOR Sign or outline lighting 53.40 2 Business name: Signal a or in d- e 1 energy , alteration, or (N Address: N extension. pan D escribbe: Page 2 2 City/State /ZIP: Each additional inspection over allowable in any of the above Per inspection 62.50 Phone: ( ) Fax: ( ) Investigation per hour (1 hr min) 62.50 CCB Lic.: Electrical Lic.: Suprv. Lic.: Industrial plant per hour 73.75 ELECTRICAL PERMIT FEES Suprv. Electrician signature, required: Subtotal: 4 . SU Print name: Date: Plan review (25% of permit fee): State surcharge (12% of permit fee): Authorized signature: C` ,i /; TOTAL PERMIT FEE: 69 -.I J / This permit application expires if a permit is not obtained within 180 Print name: -ryL of Co B ,S Date: J'J Ly ( 0 / OG l days after it has been accepted as complete. * Number of inspections allowed per permit. [:\BuildingWermits\ELC- PermitApp.doc 05/23/06 440- 4615T(11 /05 /COM/WEB Electrical Permit Application - City of Tigard Page 2 - Supplemental Information LIMITED ENERGY PERMIT FEES: RESIDENTIAL WORK ONLY: Fee for all residential systems combined .. $75.00 Check Type of Work Involved: ❑ Audio and Stereo Systems* H Burglar Alarm ❑ Garage Door Opener* n Heating, Ventilation and Air Conditioning System* ❑ Vacuum Systems* Li Other: COMMERCIAL WORK ONLY: Fee for each commercial $75.00 system (SEE OAR 918 309 - 0000) Check Type of Work Involved: ❑ Audio and Stereo Systems ❑ Boiler Controls n C • lock Systems ❑ Data Telecommunication Installation n Fire Alarm Installation n HVAC ❑ Instrumentation ❑ Intercom and Paging Systems n L • andscape Irrigation Control* ❑ Medical ❑ Nurse Calls ❑ Outdoor Landscape Lighting* n Protective Signaling ❑ O ther Total number of commercial systems: *No licenses are required. Licenses are required for all other installations I:\ Bui lding\Permits\ELC- PermitApp.doc 03/23/06 Property Owner Statement Regarding Construction Responsibilities Oregon Law requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. (ORS 701.055 (4)) This statement is required for residential building, electrical, mechanical, and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010 (7), need not submit this statement. This statement will be filed with the permit. Please check the appropriate box: I own, reside in, or will reside in the completed structure and my general contractor is: Name CCB# Expiration Date I will inform my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. or Zi I will be performing work on property I own, a residence that I reside in, or a residence that I will reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will select a contractor who is licensed with the CCB and will immediately give the name of the contractor to the office . issuing this Building Permit. I have read and understand the Information Notice to Homeowners About Construction Responsibilities, and I hereby certify that the information on this homeowner statement is true and accurate. „ ( v./ ( 047 C e.; Print Name of Permit Applicant 4 747 (:.--"1/1/5 // , cri Sig as dire olPermit Applicant Date 1 1 Permit #: i ti s � L . xn:E . Address: a k. . ( ' t ' ' ,1., • SS ice f f— Issued by:_,._) Date: // This Copy for Permit Offices 7111 q City of Tigard T I G n R D 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: Tyler Combs DATE: 7/16/09 20908 SW Winema Ct. Tualatin, OR 97062 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt #: 174306, 174307, 174308 Case #: ELC2009- 00336, '/ MEC2009 -00337 • PLM2009 -00183 • Date: 7/10/09 Address /Parcel: 10990 SW 79th Ave. Pay Method: Check Project Name: Combs EXPLANATION: Per applicant's request as project was cancelled. Refund 80% of permit fees. - �, '1' �- - ��: ,'PI.4 .. �.. . �"', :? 'i!' -'. t;.':•... • '.t +,� :ew•t c �R: ,-.. I�f xs}���('1'y /, ,• „� N,:- f•. ••.F._�. _i'�''; -. •"_ '�l3 :�:Y• �:':,;;`� -'•' F..� s.� 'r �,'. ::�. } .{. ' _ ._5.... � C� 11• ���I�OL..ut�f :��Oi'.,?. • 'ii, b R �'1!��:'�` Ji'. .!(.A./ • 14-` R�I�.r r r�.. . •�. f�.'�.' "- 1'XA�. .� � J�ii�. ': : . : �;p�s -'Aw'!jf$'+ :° y r( �Y 7 ^ -;.•- :u•, !s• ` . •-ti - .-- ,?'vi ,�;• _ a � : ; ;'.:-'.p` -- f_. 'e a g' ' :: .Vi:,.: . :'.R ciqunt . 'y, ^,- ` r# faL in. i .4, 1 }': rt . :. ;; , ..•S .,.rl ,.i. ;1'.. i fl.'1� : f: f}L'� ' L,�. � ,'i. =�+ ?_1 '�. 'r�.;+:: r_.1� . { » >._7 :f�.' ', _ .;::1 � - .�.i;.:5. ' -F��. t':,. ;, ;: . . : •' y_ _ . ,: . .$. _Ar m'aju ' ��: � � �,`- 7 .�]� I ?. � mit Fee ;: ��- �. ,�:;:?.. ,.. � Ex at�i pl e : 24 5` =' 0.0 0.0 • :._32Q00•`' : • • ., �,. :. ....,..... 0A Electrical Permit Fee 2200000 -43103 ✓ $42.80 ✓ 12% State Surcharge 1003100 -24001 ✓ 5.14 Mechanical Permit Fee 2300000 -43102 ✓ 58.00 12% State Surcharge 1003100 -24001 ✓ 6.96 •- Plumbing Permit Fee 2300000 -43101 $58.00 •• 12% State Surcharge 1003100 - 24001 ✓ 6.96 TOTAL REFUND: $177.86 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager , I len .. If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board ONLY: . _. •;, , ;- ' �'` � �:' t:;.' °F•OR ACGEI:A'SYST•EM ADMINISTRATION: L�S :;' -:; , . .. , • . . Refund Request Reviewed: Date: 2 //C By: ` Case Refund Processed: Date: / ,d.Gd' By: _ e i - ' I: \Building \Refunds \RefundRequest.doc 04/13/09 CITY OF TIGARD RECEIPT 1 111 ! gt . 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD fJ J (Avg) Receipt Number: 175175 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009 - 00336 $ - 47.94 Total: $ -47.94 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DHOWSE 09/11/2009 $ - 47.94 Payor: Tyler Combs Total Payments: $ Balance Due: $47.94 • • Page 1 of 1 III CITY OF TIGARD RECEIPT 2 : - • . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Tl[;AJD Receipt Number: 174306 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2009 -00336 Branch Circuits wo /Purchase Service or 2200000 -43103 r% $53.50 Feeder ELC2009 -00336 12% State Surcharge - Electrical 1003100 -24001 -- $6.42 Total: _ (7 $59.92 „,:f7 = :• PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $59.92 Payor: Tyler Combs Total Payments: $59.92 Balance Due: $0.00 • • Page 1 of 1 7 11 ° Community Development r 1 �; n IZ n Request for Permit Action =,; ; _ _', ; - -. ji ' All_ i. /UU`i TO: CITY OF TIGARD C i l `q OF Building Division Services Coordinator i l �a f �`� t C} 13125 SW Hall Blvd., Tigard, OR 97223 ". lr.. i t� {,, r }�� /f �� Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov FROM: le5 Owner W Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) Tyf( CoMh Mailing Address: loos' SW INti1pstst C 1 City/State /Zip: l i 41 D i 61 & 9 77 2 Phone No.: . PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( El CANCEL PERMIT APPLICATION. N . 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 #: E L L 2 - 003 6 (C l (2- OO ( 1 . 003 3 (c ) Site Address or Parcel #: /5 l3C4 otf , i f i boa `7'1 ,) ; ; 6' j f/‘4°.:— Project Name: Subdivision Name: Lot #: EXPLANATION: ii ,4 VQ0C4 f4 D�/Ot e.G� -- T , ►'Keg /" J Signature: 7 ) 4 rh Date: 4/A / Print Name: f W (a Fibs 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. (7jlnot more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Re 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 S s Admire: Date B Rte to Bld_ Admin: Date - //A5M B "jj; Refund Processed: Date 7 // Q By r !4T Invoice Processed: Date By Permit Canceled: Date 9 // el By yi'r -- Parcel Tag Added: Date By Receipt # Date Method Amount 8 I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07 CITY OF TIGARD RECEIPT p III g . 13 125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD A i r &'d1 /6 Receipt Number: 175176 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2009 - 00337 $ - 64 . 96 Total: $ -64.96 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DHOWSE 09/11/2009 $ -64.96 Payor: Tyler Combs Total Payments: $ - 64.96 Balance Due: $64.96 Page 1 of 1 CITY OF TIGARD RECEIPT i l l ill It : 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Tr GARI) 6 0C-7 fir` Receipt Number: 174307 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2009 -00337 Single Duct Exhaust (Bathrooms, Toilet, 2300000 -43102 r •,. $6.80 Utility Rooms) ` MEC2009 -00337 12% State Surcharge - Mechanical 1003100 -24001 $8.70 MEC2009 -00337 Minimum Fee Adjustment - Mechanical 2300000 -43102 $65.70'' Total: ^ • $81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $81.20 Payor: Tyler Combs Total Payments: $81.20 Balance Due: $0.00 • Page 1 of 1 I Community Development _ "I l(i� \IZD Request for Permit Action -ill; 4'• zoos TO: CITY OF TIGARD '�'r ii ! M : .3I 'S''` Building Division Services Coordinator `', tl - . il' \ "`' � = E „.,... 1, 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: tl Owner Vt. Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) 7 I,,, Gooks Mailing Address: 2D/ Q �/1/l r1 _ 8 S k/ City /State /Zip: I Va ( q ' / /1 O,e 97062 Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): ❑ CANCEL PERMIT APPLICATION. E .. 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 #: ME C200q - 00337 Site Address or Parcel #: x/513 ( .40 '6 0o A. :i , 5i.:. 4 77 — d ` Project Name: Subdivision Name: Lot #: EXPLANATION: wlk V t0 f(�5c.7 Signature: 60/10-1, Date: 7/if/el Print Name: 7 /Nr (co of j s 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 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date • By Rte to Bldg Admin: Date £ /0'‘;` By - Refund Processed: Date , ea By , " Invoice Processed: Date By Permit Canceled: Date ,�;; By Z/— Parcel Tag Added: Date - By Receipt # Date • / Method Amount $ • I:\ Building \Forms \RegPemutAction.doc Rev 07/26/07 1,111 CITY OF TIGARD RECEIPT q 1 3125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 175178 - 09/11/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 $ -64.96 Total: $ -64.96 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 100517 DROWSE 09/11/2009 $ - 64.96 Payor: Tyler Combs Total Payments: $ -64.96 Balance Due: $64.96 Page 1 of 1 III CITY OF TIGARD RECEIPT i " :: 13 125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TF (�ARO Receipt Number: 174308 - 07/10/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00183 Lavatories 2300000 -43101 - $16.60 PLM2009 -00183 Water Closet 2300000 -43101 --.')c2 J $16.60-: PLM2009 -00183 12% State Surcharge - Plumbing 1003100 -24001 ;: `••' ;, : - $8.70 PLM2009 -00183 Minimum Fee Adjustment - Plumbing 2300000 -43101 $39.304-• Total: :: L! $81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1003 LSELLERS 07/10/2009 $81.20 Payor: Tyler Combs Total Payments: $81.20 Balance Due: $0.00 • • • Page 1 of 1 7 , ° Community Development • = : : "! . Request for Permit Action : -- : ,.. TIGARD ,; . •• / LOU) h TO: CITY OF TIGARD 1 rc -. ` :r':r' Building Division Services Coordinator ` -' '' _ ` . �•`' 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: 14 Owner Applicant ❑ Contractor ❑ City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) /776C � _ 5 Mailing Address: 2o90 $ 5W w C f City/State /Zip: 7 li / 7 in 04 q 7o 6 Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): ❑ CANCEL PERMIT APPLICATION. si, REFUND PERMIT FEES (attach receipt, if available). El INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ft Al at/Off r 00163 Site Address or Parcel #: /3 J 34 CA O /6D0 6'0Cic'J' .S 7 <S7 Project Name: Subdivision Name: / / Aiu° Lot #: EXPLANATION: W /��e /OPo J ✓0 ec r' S Signature: )41/ (4111.1 Date: 7 // 4 c2 9 Print Name: T /� C&,b5 /// Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fcc 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 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date By _ Rte to Bldg Admin: Date 970 05> By , /,� Refund Processed: Date V / / /Cnj By iS' Invoice Processed: Date By Permit Canceled: Date 9/1/ /C1;: By i!'"" - Parcel Tag Added: Date By Receipt # Date % Method Amount $ I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07