PFI2014-00062 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action YA 14p,13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.
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 ❑ City Staff
(check one)
REFUND OR Name: Jesus Sierra
INVOICE TO: (Business or Individual)
Mailing Address: 278 Sandy Dr.N
City/State/Zip: Sandy, OR 11,73oS
Phone No.: 503-390-4421
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT 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#: PFI2014-000(0,2
Site Address or Parcel#: 11110 SW Summerlake Dr.
Project Name: Paris
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Homeowner changed mind about wanting to do the work.
Signature: Ojyt.�k C Date: 8/25/14
Print Name: Che C ales
ole ��o 6/0
Refund Policy A
1. The cit3/s CommunityDevelopmern Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of application fees when application is withdrawn/canceled before review effort has been expended or for issued permits,
prior to any inspection requests.
2. The city s Engineer may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 50%of application fees when application is withdrawn/canceled before review effort has been expended or for issued permits,
prior to any inspection requests.
3. All refunds will be returned to the original payer in the form of a check Please allow 3-4 weeks for processing refund requests.
OR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Records: Dated
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: Date B el Tag Added: Date _--+B
Receipt# Date Method Amount$
I:\Bdding\Forrris\RcqPennkAction-082114.doc
City of Tigard
Public Facilit�T Improvement
■
(PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 1&ZO , S 0 jNA_V le y I(\uQ_ Engineering!2O/, l�aQ��p o�
---� / p 7 Case No.: �f,
c]►�• I'C.tC�I� �(� 7 �v� \ Fee: ��/.fid 3/0nd — �SOd•O!�
Receipt No.: 6
17 32-
*Applicant's>Name: .,CDYJ5 S 1 e Ywlo Date:
Address:'— QSC�1��1 U!nY !V - Application Accepted: By:
City/State: KEQ V r 04 3E Zip: -1
Primary Contact: J e'sC)S SX(� Y,cv\ REQUIRED SUBMITTAL
Phon
.S Z& V4eg2 Fax: INFORMATION
E-Mail: Professional Engineered Plans are required
for:
I • Street Widening
C Contractor's Name: J cs lac t P,rrCA
� C"C��# l 3669
� • Subdivision Infrastructure
Expiration: • Main utility line extension:
Address: 'ZI 9 /U, 0 Storm Drain,Sanitary—Tigard
�,,1 0 Water—Tigard Water Service Area
City/State: �(��' /rte`/ r Zip: /< (includes Durham,King City and a
S o3 3 Fa TT�/ Fax: portion of unincorporated Washington
Phone: County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work Submit scaled sketch of the
City/State: lip: work to be done.(see attached minimum sketch
Phone: Fax: requirements and provided sketch area).
Updated:6/24/2013
Jf I J 1:\CURP1 N\Masters\1$nd Use Applications\Public Facility
Description of work: 1 r Y� C y Y �f--� QX
Impnwcm ,tdoc�
it
Estimated value of work(within the public right-of-way): $ 0
J 13
Is work related to a LAND-USE DECISION? YES F-] NO
If so,please specify(MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES F—] NO ❑
If so,please specify(BUILDING PERMIT)case#:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov Page 1 of 5
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: All non-water system improvements
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee= Part 1+Part 2
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is$50.00 per address.
L
SAMPLE -�
Minimum Sketch Requirements
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(sewer,water,storm)
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.dgard-or.gov I Page 3 of 5
SKETCH AREA:
City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov Page 5 of 5
1
� i
City of Tigard
September 18,2014
Jesus Sierra
278 Sandy Drive N
Sandy, OR 97303
Re: Permit No. PFI2014-00062
Dear Mr. Sierra:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11110 SW Summerlake Dr
Project Name: Paris
Job No.: N/A
Refund Method: ® Check#214995 in the amount of$1,900.00.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
—- ---Comment(s): : er app cants request as home owner changed mind on completing -
work. Refund 100% of application and permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of 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 Req&estforPermitAaion 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: Jesus Sierra DATE: 9/10/2014
378 Sandy Drive N
Sandy, OR 97303 REQUESTED BY: Dianna Hoxvse
CC
TRANSACTION INFORMATION:
Receipt#: 197324 Case#: PFI2014-00062
Date: 8/20/2014 address/Parcel: 11110 Ste'Summerlake Dr
Pay Method: Cash Project Name: Paris
EXPLANATION: Per applicant's request as owner changed mind. Ok to refund 1009/6 per Zen Dutson.
REFUND INFORMATION:.
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Customer Deposit 100-0000-22000 $1,600.00
PFI Permit Fee 100-0000-43114 300.00
TOTAL REFUND: $1,900.00
APPROVALS: SIGNATURES DATE:
If under$5,000 Professional Staff v�
If under$12,500 Division Nfanager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Revie%v Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: 1 7 /� / B
I:\Building\Refunds\RefundRequest.dru s 09/01/2010