Permit �� CITY OF TIGARD /° Aged" SEWER CONNECTION PERMIT
311 = COMMUNITY DEVELOPMENT Permit#: SWR2014-00017
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/05/2014
Parcel: 1 S136CC00100
Jurisdiction: TIGARD
Site address: 8200 SW PFAFFLE ST
Project: Westside Christian High School Subdivision: 2006-016 PARTITION PLAT Lot: 3
Project Description: 4.31 EDU increase.Original.38 EDU. 3/11/14, PLM2014-00060 revised for new total of 1.00 EDU. 3/13/14,
revised for new total of 4.81 EDU.3/17/14, revised for new total of 4.94 EDU. 10/23/2014 revised for new total of
5.31 EDU. 10/23/2014 revised for new total of 4.56 EDU. 11/17/2014 revised for new total of 4.31 EDU.
Contractor: Owner: WESTSIDE CHRISTIAN HIGH SCHOOL
4565 CARMEN DRIVE
LAKE OSWEGO, OR 97035
PHONE: PHONE: 503-697-4711
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 03/05/2014 $1,824.00
Sewer Connection Fee 03/12/2014 $3,024.00
Type of Use: COM Sewer Connection Fee 03/18/2014 $624.00
Class of Work: ALT Sewer Connection Fee 10/28/2014 $1,824.00
Install Type: Building Sewer Sewer Connection Fee 03/17/2014 $13,392.00
Fixture Units:
Number of Dwelling Units: 4.31
Total $20,688.00
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 by calling 503.232.1987 or 1.800.332.2344.
Issued By: i1 5�(3ri C Kam— Permittee Signature: i,x/ /920/04.,69770"../
�-F� 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.
Accy
;� - Tenant Name: Westside Christian High umul Schatioove l Sewer Tall
SWR# 201400017_REV6
TIG1 RD Site Address: 8200 SW Pfaffle St PLM# 2014-00060
Parcel#: 1 S 136CC00100
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptisery/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: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher: -Commercial 1 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 8 16 8 16
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
-
Ice Machine/Refrigerator Drain 1 0 0 1 1 1 1
Living Unit 16 0 0 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 6 12 6 12
Sink:
-Lay/Bar-Non-Food Related 2 0 0 5 10 5 10
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 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 0 0 3 18 3 18
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 _ 0 0 0 25 69 25 69
Current Fixture Value 69 divided by 16= 4.313 Current EDU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 69 divided by 16= 4.313 over (under) $ 20,688.00
Enter EDU Change Here 4.310
Notes:3/11/14:add(5) floor drains to scope of work. 3/13/14,add(6)showers,(1)whirlpool,(1)_ice machine,(4)lays,(3)toilets&(1)urinal.
3/17/14:add(1)lay. 10/23/14:add(1)clothes washer.10/23/14:correct(6)tub/showers to shower stalls. 11/17/14:remove(1)whirlpool.
Authorized Name/Signature: Dianna Howse Date: 11/17/2014
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_4800._070113.xlsx
L
T I GARD
City of Tigard
December 2, 2014
Westside Christian High School
4565 Carmen Drive
Lake Oswego, OR 97035
Re:Permit No. SWR2014-00017
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 8200 SW Pfaff le St
Project Name: Westside Christian High School
Job No.: N/A
Refund: ® Check#215751 in the amount of$4,896.00.
0 Credit card "return"receipt in the amount of$
0 Trust account"deposit" receipt in the amount of$
Notes: Per applicant's request as whirlpool tub was removed from scope of work resulting
in a refund of the sewer connection fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
■
d l
Dianna Howse
Building Division Services Coordinator
Enc.
I:\Building\RefunIXt iii iK43.UR ,if3ioN04)iga" 1Omagon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
i City of Tigard
TIGARD Accela Refund Request
e
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Requestftr 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: Westside Christian High School DATE: 11/17/2014
4565 Carmen Dr
Lake Oswego, OR 97035 REQUESTED BY: Dianna Howse
DA
TRANSACTION INFORMATION:
Receipt #: 195258 Case #: SWR2014 00017
Date: 3/17/2014 Address/Parcel: 8200 SW Pfaffle St
Pay Method: Check Project Name: Westside Christian High School
EXPLANATION: Amend EDU fixture count from (6) tub/showers to (6) shower stalls reducing total
EDU amount and remove (1) whirlpool tub from scope of work.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Sewer connection fee 500-0000-25500 $4,896.00
TOTAL REFUND: $4,896.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff /Zil"S l.7f--e--- /2/2,-1/4
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: Date: /2/,2• y By: /f5144---
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
T I G A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
10: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor El City Staff
check(✓) ,n
REFUND OR Name:
INVOICE TO: (Business or Individual) L 3 j j C kesr�j�� u,(' i 6c,
Mailing Address: q5(,5 C AQ 1 —D12.4 L.
City/State/Zip: } 06(4.3f-Go (17• 35-
Phone No.: 5-023- 69-7- J-71 (
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
. ► f •ID PERMIT APPLICATION.
REFUND ' ' IT FEES (attach copy of original receipt and provide explanation below).
d� . : FOR FEES DUE (attach c: - -e schedule and provide explanation below).
❑ REMOVE/REPLACE C• • ' CTOR ON PERMIT (do not cancel permit).
Permit#: 3w �U( DUO( - Ir . . 0
Site Address or Parce
Project Name: E-- att X9-4 -t A t ('off `o C
Subdivision Name: Lot#:
EXPLANATION: �t u� �ek, Pf}y Mi T C7 ��u, 6DC. IEtS
'but TT t�1CoQ c T Otitss,t=,C.FTo of , [4) Ot') 4
C-4.4551142 E.-"D A'S T6 3.11101.4t/L6 R/ ,r5 LJkfJ —THEY wff. woe. 9L 5 A Arts blea 4.67-10 VET D 4iL
t /a9 1.,44 /0i,'1 E Ss ) / `Signature: t�y ,aA-i Date: / 4,/
Print
Print Name: / ° 2`'
Refund Policy pun /. co _ /.ao = �`
3
1. The city's Community Development Director,Building Official or City 11 —
- - PL.i he refun o D a •�'�
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests. �ll�Q O a. s j'1/ 0-0
AfE•iti Eau. n2 o, cti
cflez 44;:r-u.vA V�9W . aD
I OR OFFICE USE ONI.I
Route to S s Admin: Date a EgYFAINUILTM Route to Records: Date B . AM
Refund Processed: Date/_ 'At,/ By •i Invoice Processed: Date By
Permit Canceled: Date/1// By c Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_($ii 4.doe
,, CITY OF TIGARD SEWER CONNECTION PERMIT
3 • COMMUNITY DEVELOPMENT Permit#: SWR2014-00017
T f G A R D 13125 SW Hall Blvd..Tigard OR 97223 503.718.2439 Date Issued: 03/05/2014
Parcel: 1 S 136CC00100
Jurisdiction: TIGARD
Site address: 8200 SW PFAFFLE ST
Project: Westside Christian High School Subdivision: 2006-016 PARTITION PLAT Lot: 3
Project Description: 38 EDU increase. 3/11/14, PLM201 4-0006 0 revised. an additional 63 EDU's added for a new total of 1 01 EDU's
Contractor: Owner: WESTSIDE CHRISTIAN HIGH SCHOOL
4565 CARMEN DRIVE
LAKE OSWEGO. OR 97035
PHONE PHONE 503-697-4711
FAX
FEES
Description Date Amount
Specifics: Sewer Connection Fee 03/05/2014 $1.824 00
Sewer Connection Fee 03/12/2014 $3,024 00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 38
Total $4.848.00
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 by calling 503.232.1987 or 1.800 332.2344.
Issued By: �� fir— G Permittee Signature:
Call . . y 7:00 a.m.for the next available inspection tlate.
This permit card shall be kept in a conspicuous place on the job site until completion of the pt6ject.
Approved plans are required on the job site at the time of each inspection.
IIIIII Accumulative Sewer Tally '
Tenant Name: Westside Christian Church-REVISED SWR# 2014-00017
Site Address: 8200 SW Pfaftle Sr PLM# 2014-00060
Parcel#: 1S136CC00100
I ixturc Value I't,Mani• Previous Credits Capped Fixture Fixture New New
:: value count capped#s %clue count added# added value total#s :„tal values
liaptisery/font 4 0 11 0 0 0
Bath: -Tub/Shower 3 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 11 0 0
Dishwasher. -Commercial 4 0 0 0 0 0
- Domestic _' 0 0 0 0 II
Drinking Fountain I (1 11 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 5 10 5 10
-3 inch 5 0 0 0 0 I I
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 1 FP) 16 0 0 0 0 0
-Commercial(to 5 111') 32 0 0 0 0 0
-Industrial(over 5 I II') 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 n 0 0 II
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
Rec.Vehicle Dump station Ii, 0 0 0 0 0
Shower. -Gang(per head) I 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-Bradley _ 0 0 0 0 0
-Com/Scrv/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 11 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 _. 10 5 10
Current Fixture Value 10 divided by 16= 0.625 Current I:DU 1 EDU= $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 10 divided by 16= 0.625 over (under) S 3,024.00
Enter EDU Change Here 0.630
Notes: 3/11/14,adding(5)additional floor drains to scope of work.
Authorized Name/Signature: Debbie Adamski Date: 3/11/2014
Building Division
Note: The property owner shall retain the(WI( I\ \1.sewer tally record. I f 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.
1:\Building\Sewer Tally\Sewell allySheet_48t t 1,_070113,xlsx
CITY OF TIGARD SEWER CONNECTION PERMIT
■ COMMUNITY DEVELOPMENT Permit#: SWR2014-00017
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/05/2014
T t t' 'L7 9 Parcel: 1 S136CC00100
Jurisdiction: TIGARD
Site address: 8200 SW PFAFFLE ST
Project: Westside Christian High School Subdivision: 2006-016 PARTITION PLAT Lot: 3
Project Description: .38 EDU increase
Contractor: Owner: WESTSIDE CHRISTIAN HIGH SCHOOL
4565 CARMEN DRIVE
LAKE OSWEGO, OR 97035
PHONE: PHONE: 503-697-4711
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 03/05/2014 $1,824.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .38
Total $1.824.00
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 suspe •-• • .ore the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. T .se rules are t forth in OAR 952 001-0010 through OAR 952-001-0090. You m- 'n a copy of the rules or direct questions
to OUNC • calling 503.232. !• o 1 • 6.332.2344.
Issue. By: Permittee Signat• /* `♦/
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.
Accumulative Sewer Tally
Tenant Name:Wcstsidc Christian Church-Gymnasium SWR# 2014-00017
Site Address: 8200 SW Plaftle St PLM# 2014-00060
TIGARI)
Parcel#: 1S1 36CC00100
liixture Value Previous Previous Credits Capped Fixture 1ixturc New New
# value count capped#s value count added# added value total#s total values
Baptisery/Font 4 0 (I 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 (I 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 (I 0 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 (1 0 3 6 3 6
-3 inch 5 0 (1 0 0 0
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
Living Unit 16 0 0 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 (1 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food RelatL,1 2 0 0 0 0 0
-Bradley ? 0 _ (I 0 0 0
-Com/Serv/Util-Food Related i 0 0 0 0 0
Swimming Pool Filter 1 0 (I 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 _ 0 0 0 3 6 3 6
Current Fixture Value 6 divided by 16= 0.375 Current EDU 1 EDU _ $4,800.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 6 divided by 16= 0.375 over (under) S 1,824.00
Enter EDU Change Here 0.380
Notes:
Authorized Name/Signature: Debbie:ldamski Date: 3/4/2014
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.
1:\Building\Sewer Tally\SewerTallyShect_4800._070113.xlsx