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Permit CITY OF TIGARD PLUMBING PERMIT III s, COMMUNITY DEVELOPMENT AIM Permit#: PLM2014-00010 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/14/2014 Parcel: 1S126 DC04800 Jurisdiction: Tigard Site address: 9495 SW LOCUST ST G Project: Oregon Medical Research Subdivision: LEHMANN ACRE TRACT Lot: 4 Project Description: Capping off(5)RP devices and(1)mop sink.3/20/14 REPRINTED,removing(4)RP devices and(1)mop sink from scope of work. Only(1)RP device to be capped Contractor: VENNE PLUMBING LLC Owner: MATHESON, ROBERT T REVOCABLE TRU 15145 SW DIVISION ST BAKER, JAMES SHERWOOD, OR 97140 BAKER. DIANE R 1030 NW JOHNSON ST#610 PORTLAND, OR 97209 PHONE 503-624-9309 PHONE FAX: 503-684-0940 FEES Quantity Description Date Amount 6 ea Fixture/Sewer Cap 01/14/2014 $150 12 Specifics: 1 12%State Surcharge- 01/14/2014 $18.01 Plumbing Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total S168 13 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 through OAR 952-001-0090 You may obtain a copy of the rules or direct-questions to OUNC b calling 503.232.1987 or 1.800.332.2344 Is ued By: Permittee 3ignatu : Call 503.639.4175 by 7:00 a.m.for the next available inspection date. 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. Plumbing Permit Application Building Fixtures dE1' iVFD City of Tigard Received Permit No: 4 13125 SW Hall Blvd.,Tigard,OR 97223 9 0 7(114 Date/By: 1�, 1 Li / j� -vU0/Q u Plan Review Phone: 503.718.2439 Fax: 503.598.19413 Date/By: Other Permit No.: Inspection Line: 503.639.4175 .T I tA R D . Date Ready/By: Juris See Page 2 for Internet. www,ti ard or. ov V T i !lUf1} V Notified/Metod: S upplemental Information .rRr: - TYPE OF WORK FEE* SCHEDULE ❑New construction ❑Demolition For special information use checklist. Description I Qty. I Ea. I Total ❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(I)bath 312.70 ❑ I-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 building SFR(3)bath 500.32 ❑Accesso ry g ❑Multi-family Each additional bath/kitchen 25.02 ❑ Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: �1 , '9 { I C /..t--.4 Catch basin or area drain 18.76 Job site address: `fie( {} f- i Drywell,leach line,or trench drain 18.76 City/State/ZIP: /� Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: Project name: ZAtelie_vi jl/�I A Lei) Manufactured home utilities 50.03 Cross street/directions to job site: t� e t 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.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 � f Clothes washer 25.02 l' j`Lll tiali):4- ~ `'�,l ,� U Dishwasher 25.02 I Vc -1 ,yL U Drinking fountain 25.02 Ejectors/sump 25.02 ❑ PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 Name: Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 ❑ APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02 Business name: Medical gas(value:S ) Page 2 Primer 12.51 Contact name: Roof drain(commercial) 12.51 Address: Sink/basin/lavatory 25.02 City/State/ZIP: Solar units(potable water) 62.54 Phone:( ) I Fax::( ) Tub/shower/shower pan 12.51 E-mail: Urinal 25.02 CONTRA OR Water closet 25.02 `,� Water heater 37.52 Business name; u'�4� 'U--fh/01.t Water piping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Minimum permit Ice: $72.50 Phone:( ) Fax:( ) _ CCB Lic.: . Plumbing Lic.no.: Plan review (25%of permit fee) / State surcharge(12%of permit fee) Authorizedsignature�`�� -/ TOTAL PERMIT FEE . _ Print name: �� This permit application expires if a permit is not obtained within 180 days f� �; a Date: ,2D. I after it has been accepted as complete. *Fee methodology set by Tri-County Building Industry Service Board. I 1BuildinglPermita1PLMl.`•PcrmilAppd0c 10/01.09 440-46167(10/071COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee: Footing drain- lB1 100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 S 169.69 3,601 to 7,200 $233.20 Sewer-1st 100' 62.54 7,201 and greater $327.54 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee: $1.00 to$5,000.00 Minimum fee$72.50 Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for Other Inspections or Fees Qty Fee(ea) Total each additional$100.00 or fraction thereof,to I� and including$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to (minimum charge-1/2 hour) and including$25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to Reinspection Fees 90.00/br and including$50,000.00. Additional plan review for revisions 90.00/hr $50.001.00 and up $742.00 for the first$50,000.00 and$1.20 for (minimum charge-1/2 hour) each additional$100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations Quantity by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate ❑ Any new commercial building with water service 2"and Baptistry/Font greater,except systems designed and stamped by licensed Bath: -Tub/Shower engineer. -Jacuzzi/Whirlpool Car Wash: -Each Stall C3 New exterior plumbing site utilities for any complex structure Drive Stall as defined in OAR918-780-0040. Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities. Dishwasher. Commercial CI Any multipurpose fire sprinkler system. Domestic El Any complex structure as defined in OAR918-780-0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" -3" Isometric or Riser Diagram -4" ❑ Isometric or riser diagram is required for new buildings -Car Wash Dram Garbage -Domestic non-food that meet the qualifications above. Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower. -Gang -Stall Sink: -Lav/Bar non-food related -Bradley -Com/Serv/Util food related -Service *Note: If the fixture work under this permit results in an Swimming Pool Filer increase of sewer EDUs,a sewer permit will be issued and Washer-Clothes fees assessed for the sewer increase must be paid before the Water Extractor WaterCloset-Toilet plumbing permit can be issued. Urinal Other Fixtures: 1:1Building\Permits\PLMF_PcrmitApp.doc 08/04/2011 2 CITY OF TIGARD PLUMBING PERMIT R COMMUNITY DEVELOPMENT Permit N: PLM2014-00010 Date Issued: 01/14/2014 TI( A R O 13125 SW Hall Blvd..Tigard OR 97223 503.718.2439 Parcel: 1 S 126QC04800 Jurisdiction: Tigard Site address: 9495 SW LOCUST ST G Project: Oregon Medical Research Subdivision: LEHMANN ACRE TRACT Lot: 4 Project Description: Capping off(5)RP devices and(1)mop sink. Contractor: VENNE PLUMBING LLC Owner: MATHESON, ROBERT T REVOCABLE TRU 15145 SW DIVISION ST BAKER,JAMES SHERWOOD, OR 97140 BAKER, DIANE R 1030 NW JOHNSON ST#610 PORTLAND,OR 97209 PHONE: 503-624-9309 PHONE: FAX: 503-684-0940 FEES Quantity Description Date Amount 6 ea Fixture/Sewer Cap 01/14/2014 $150 12 Soecifics: 1 12%State Surcharge• 01/14/2014 $18.01 Plumbing Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total S168 13 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 issu ce, or if work suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon U ity Notification Cente. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0'90. You may obtain a copy of the rules r direct questions to DUN • all 503.232.1987 or 1.800.332.2344. ssued By: / Permittee Signature: Call 503.639.4175 by 7:00 a.m.for the next available ins• • date. 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. 2014-01-13 14:39 VENNE PLUMBING 5036840940 » 5035981960 P 2/2 Plumbing Permit Application Site Utilities RECEIVED FOR 4WFI- F I SI ()NI 1 City of Tigard N":""oa Fbmtil No.: 13125 SWflulHlvd.,Ti�vd,OR07 ,Lm ® �I [/i' 3/ -elCalD Phone: 503.718.2439 Fax: 503.5 13 2014 ) Hew Other Permit No. thienly his/xenon Lira: 503.639.4175 [hot Ru.I r nt r: ].n, ® See)see z for Intguner www.ugard-ougav CITY OF'TIGARD _NaliIiea/Mcthpd: , 1 Soeptemcet,t leforntalinn T'''� °!'1 V ISION FEE* SCHEDULE. ❑New cIm>ttttt tiara Q Iktnatlit;tor 1 , For special ornwrimrrcvr(*ecrli t kscri hon Qt Y. Ea 1 Total $rAdditicut/alteration/ttplacetnent Q Other: New 1-2-family•dwelli (includes IUO ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(I)bath 312.70 • 1-and 2-family dwelling Co nmercial/indusirial 5I R(2)bad 437 71 -_ ❑Accessory huilding ❑Multi-family SFIT(3)bath 511102 Fitch additional bath/kitchen 25.02 ❑Master builder ❑Othcr: Dire yxmkl-r( sq.IL) Page 2 JOB SITE INFORMATION AND LOCATION site utilities: Catch basin nrarea drain 18.76 Job site address: 1!���,-. 5�,(,) �f(,�ST . City/StateiLlP: '7`t o A'R D 0 at-11z Clcywcll.leach lute or trench drain I 8.76 Footing drain(no.linear IL._) Page 2 Suitc/hlti(;.lal►l.nu.: Project name: (AL 1. 4 It t;� Manufactured home utilities 50.03 Cross titrect/dircctiotls to job site: Manholes 1$.76 Kant drain connector 18.74 - Stmilary scwcr(no.linear IL: ) hic 2 Shorn sewer(no.linear It.:_) Page 2 Water (no.linear ft.: ) Page 7 , Subdivision! Let nu.; ixhi a or Item: Hack now prevcnter X31.27 1 ax ntap/parcel no.: DESCRIPTION OF WORK 13ackwetcrvalvc 12.51 Clothc5 w.nhcr 21 112 SA I N O 4c-r V 1 ;V 1 C l I) Dim washer 25.02 0 h7E M 0 p S Ii+) _ I./finking fountain 25.02 Ejectors/sump 25.02 ❑ PROPBR'1'Y OWNER 1 Q TENANT T:xpetuwrt oink t 12,51 . Fixture/sewer cap 4. CI? 23.02 (5d•i-z- Name: Address: - Floor drain/tloorsink/hub 25.02 Garbalte disposal 25.02 cay/Sunc/ZIP: !lose bib 25 Pltonc:( ) Fax:( ) Ice maker 12.51 XilAPYLK:ANT ❑ CONTACT PERSON Inlercgtmdgrcasc trap 25.02 nILSinb39 Mine'U E-I`I P LAt fli( I�i NC--1 1. Medical (value 5,) I'ty�e 2 Pnmcr 12.51 Contact name: 12-YA-1v • (ss)I - Hour drain(comma-ciao 1151 Address I I 14 S ,1.) Pi\I 1 S i (HO c4- Sink/basinflaratory j 25.02 1 City/Slate/ZIP: SK-6-11._.LA)000 0 r` 17 NO Solar units(potable wilco (11.34 Phone:6..x.#) bz q -ct o g Fax::( ) (at( Oq 1 l) •I'uh/tihow©r/shower pan - 12.51 - Uritud 75.02 E-mail: RY (d Vh�NNEPL.umoiNe. (0M - Water closet 25.02 CONTRACTOR Water beater 37.52 Business name: eve C. Pa. PCtr L I C+°1/44.-11- N'wet piping/MIN 56.29 Addrt sc: Other: 25.02 Cily/StatctLIP: _ Subtotal 1�J0+I 2 Plum:( ) Fax:( ) Minimum permit fee: $72.50 - CCIl Liu.; 1 -L 7-4 q -L J� Plumbing I.ie.nu.: P a Plan review (25%I>f'permit fix) l R,�'l, State surcharge(12%of permit tic) Authorized signal-lam 4 TOTAT.PI?HMITI'F'FF ^'rJ ._ Print name: te3Wr VC. kl ne, Uan 12.2 _z613 7 his permit a'pl i1er i t e La a as'r h p a a ompLtetnee,d wind.I NU men •I're methodology set by Tri-Cmmly Iiaikdrng taduetry Scr+ics:B..:.d 4 t I.1BuilJinulPrnnic,.Vim ll-vem,nnpp nr,: rnm,p,+o 1d4 Ioroli tunR,CIIN.WFa) / /CY„Q r V 01 1,111 Accumulative Sewer Tally "� '1'enantName: Oregon Medical Research "CREDITS** SWR# N/ \ Site Address: 910;S11 la wust tit Suite t; PLM# 2014-00010 I ( \Li) Parcel#: 1 S126DC04800 Fixture Value Previous Previous Credits Capped I;ixture Fixture New New # value count capped#s value count added# added value total#s h■tal values Baptistry/Font 4 0 0 0 0 0 Bath: -Tub/Shower 4 0 0 0 0 0 -Jacuzzi/Whirlpool 4 0 0 0 0 0 Car Wash: -Isach Stall 6 0 0 0 0 0 -Drive through 16 0 0 0 0 0 Cuspidor/Water Aspirator 1 II 0 0 0 0 Dishwasher -Commercial 4 I I I I 0 0 0 -Domestic _ 11 0 0 0 0 Drinking Fountain I 0 0 0 0 0 Eye Wash 1 0 (I 0 0 (1 Fluor Drain/Sink: -2 inch 2 0 0 0 0 0 -3 inch 5 0 (I 0 0 0 -4 inch 6 0 0 0 0 0 -Car Wash 6 n 0 0 0 0 Garbage Disposal: -Domestic(to 3/4 III') 16 0 ! II 0 0 0 -Commercial(to 5 I IP) 32 0 I I 0 0 0 -Industrial(over 5 I IP) 42 0 11 0 0 0 Ice Machine/Refrigerator Drain I 0 0 0 0 0 Living Unit I6 0 11 0 0 0 Oil Sep(Gas Station) 6 0 0 0 0 0 Rec.Vehicle Dump station 16 0 0 0 0 0 Shower: -Gang(per head) 1 0 0 0 0 0 -Stall 2 0 0 0 0 0 Sink: -Lav/Bar-Non-Food Related _' 0 0 0 li 0 -Bradley 5 0 0 0 0 I 0 -Com/Seri/Util-Food Related 3 0 1 3 0 -1 -3 Swimming Pool Filter 1 0 0 0 0 0 Washer-Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet-'link; 6 0 0 0 0 0 Urinal 6 0 0 0 11 0 Previous EDU t:oum 0 0 Capped EDU Credit 0 TOTALS 0 0 1 3 0 0 -1 -3 Current fixture Value -3 divided by 16= -0.188 Current IsDU 1 EDU = $4,800.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change -3 divided by 16= -0.188 over (under) S (912.00) Enter EDU Change Here -0.190 Notes: .CREDITS** Authorized Name/Signature: Debbie.\damski Date: 1/14/2014 Building Division Note: The property owner shall retain the ORIGIN.\l.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(level'pmcnt charges. I:\Building;\Sewer'I'ally\Sewer I'allySheec_48.00._070I 13.xlsx CC---- ErCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request Permit Action TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • wwwaitzalyd-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 ECCity Staff (check one) REFUND OR Name: I INVOICE TO: (Business or Individual) V f, ti G L tA� Q (.N)G.11/43 Mailing Address: +5 i rSC )T'0 IIIO l3 1 City/State/Zip: t\k E.IQ L.306b? 02 c7 1 LiO Phone No.: np,3 - CD aLi- 9 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ i ► VOID PERMIT APPLICATION. 4002 REFUND RMIT FEES (attach copy of original receipt and provide explanation below). ■ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). Permit#: Lt-1 (9.p lit --6CC) l 0 Site Address or Parcel #: q`. 9 LD bt.0 Le 2 a r C Project Name: 012E.Coon) l_'7D 1 CAL `h er4iee_ii Subdivision Name: Lot #: --5 _,-totAk.)}-(o tA &) E (q) la p -D60 I Ci S a 6) io P 5I to P. rk_o rH CG PE Cr L,..)00._v.,, Signature: / .0 Date: ')oho 114 Print Name: t 1i)/j I L tot-, 161- 1,4 S k 1 / jG,,Np 6..2, /0 ,2 t/d 6fMtL Refund Polity l re li of -47,--5-7:9-.7. �/.S I—' oe. zt:re . 1. The Director or Building Official may authorize the refund of: (0 e#7°■°m dri 70 74s a) any fee which was erroneously paid or collected. xi2es�� • .11 Ao qe /5,c b) not more than 80%of the land use application fee when an application is withdra r caac e9�fore any review effort /*.P4 r c) not more than 80%of the land use application fee for issued permits. Q• 3/ 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. Lri1 p,SO 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 rem r sfs. !!�O I OIt OI I ILL l tit. ()N.1.\ Rte to S s Admin: Date _ rffigrirreLlM Rte to Bld:Admin: Date AWAS121 B •;;� Refund Processed: Date/2/ /y By .ii. Invoice Processed: Date By Permit Canceled: Date ,/ 41- By, L. Parcel Tag Added: Date B Receipt# Date Method Amount S I:\Building\Forms\ReyPermitAction.doc Rev 05/25/2012 1 CITY OF TIGARD f PLUMBING PERMIT "l1 s • COMMUNITY DEVELOPMENT d'� /4 . ■ 2 Permit#: PLM2014-00010 Date Issued: 01/14/2014 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1S126DC04800 Jurisdiction: Tigard Site address: 9495 SW LOCUST ST G Project: Oregon Medical Research Subdivision: LEHMANN ACRE TRACT Lot: 4 Project Description: Capping off(5)RP devices and(1)mop sink.3/20/14,REPRINTED,removing(4)RP devices and(1)mop sink from scope of work. Only(1)RP device to be capped. Contractor: VENNE PLUMBING LLC Owner: MATHESON, ROBERT T REVOCABLE TRU 15145 SW DIVISION ST BAKER,JAMES SHERWOOD,OR 97140 BAKER, DIANE R 1030 NW JOHNSON ST#610 PORTLAND, OR 97209 PHONE: 503-624-9309 PHONE: FAX: 503-684-0940 FEES Quantity Description Date Amount 6 ea Fixture/Sewer Cap 01/14/2014 $150.12 Specifics: 1 12%State Surcharge- 01/14/2014 $18.01 Plumbing Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $168.13 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 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC b calling 503.232.1987 or 1.800.332.2344. Is ued By: 4-1161 Permittee Signatule ¢ t(--/-1-Z.-C—//7 Call 503.639.4175 by 7:00 a.m.for the next available inspection date, 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. City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Venne Plumbing DATE: 3/31/2014 Attn: Jeremy Pontow 15145 SW Division St. REQUESTED BY: Dianna Howse Sherwood, OR 97140 TRANSACTION INFORMATION: Receipt#: 194528 Case#: PLM2014-00010 Date: 1/14/2014 Address/Parcel: 9495 SW Locust St., G Pay Method: CreditCard Project Name: Oregon Medical Research EXPLANATION: Per applicant's request as scope of work changed. Cap only(1) fixture, and refund 80% of permit fees paid for(4) other capped fixtures. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Plumbing Permit 230-0000-43101 $62.10 12% State Surcharge 100-0000-24001 7.45 TOTAL REFUND: $69.55 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: J Date: ,"/j"///, - I:\Building\Refunds\RefundRequest.doc x 09/01/2010 Location: Record Type: Inspection Type: Comments: Inspection Date: Record ID: Result: City of Tigard 13125 SW Hal Blvd. Tigard, OR 97223 Tel: 503.718.2439 9495 SW LOCUST ST G, TIGARD, OR, 97223 Commercial - Plumbing 399 Plumbing final 2014-03-24 (null) PLM2014-00010 PASS - No C of O Cap off 4-ea rp devices for dental equipment and hard cap one floor sink Violation Summary: Inspector Contractor