Permit •
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
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Request Permit Action �0 b Ay,
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T 1(i A R I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www • EP
TO: CITY OF TIGARD
Building Division Services Supervisor OCT 21 2014
13125 SW Hall Blvd.,Tigard,OR 97223 (;�' 'Y OF TIGARD
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
UILDING DIVISION
FROM: ❑ Owner pplicant El Contractor City Staf
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) pi)14A,, pi tkvn b! Al (6
Mailing Address: rD e)oy. 1611/1 S
City/State/Zip: PD ItGU'i41 b . 9 ag b
Phone No.: 03 - 214E4- /9'6 0
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
El CANCEL/VOID PERMIT APPLICATION.
rs REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
MI INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: 5W 12. 2-OM14- 0 010- 1
Site Address or Parcel#: ) ()V.-0 S uJ (31r.Q�Pu j Rot . 2S-7)
Project Name: SpcX 0
Subdivision Name: Lot#:
EXPLANATION: po w.en. P 1(kwt b) ' GU d- 1/10- d a j611 —
. ./L I '1 4 Q /1 .0 . 1 A &... PU i .
•
Signature: , I • 1 ID c.--" Date: 10 /2! 'iii
Print Name: , a.U. V"-C4- b CO S
&fund Policy
1. The Community Development 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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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 SO%of the building 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. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE 11SE ONLY
Rte to S s Admin: Date 1 A NM B, Rte to Bld• Admire: Date /D r' C .7
Refund Processed: Date / mi B' SErli Invoice Processed: Date B
Permit Canceled: Date mp , it By a;Z ga arcel Tag Added: Date By
Receipt# Date Method Amount$
I;\Building\Forms\RegPemutAction_062tl 14.doc
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TIGARD
City of Tigard
October 30, 2014
Power Plumbing
Attn: Laura Deos
PO Box 19418
Portland, OR 97280
Re: Permit N6. SWR2014-00107 PLM2014-00328
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10220 SW Greenburg Rd., #250
Project Name: Sodexo
Job No.: N/A
Refund Method: ® Check#215425 in the amount of$715.46.
❑ Credit card "return" receipt in the amount of$
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): Per applicant's request as customer cancelled job. Refund 80% of
plumbing permit fees $78.46 plus 100% of sewer connection fees $637.00 for a total refund
of$715.46.
If you have any questions please contact me at 503.718.2430.
Sincerely,
ZL�
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
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 forPermit 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: Power Plumbing DATE: 10/23/2014
Attn: Laura Deos
PO Box 19418 REQUESTED BY: Dianna Howse
Portland, OR 97280
TRANSACTION INFORMATION:
Receipt#: 197840 Case#: SWR2014-00107
Date: 10/2/2014 Address/Parcel: 10220 SW Greenburg Rd#250
Pay Method: CreditCard Project Name: Sodexo
EXPLANATION: Customer cancelled job and work performed by another contractor. Refund 100% of
CWS sewer connection permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Sewer connection permit 500-0000-25500 $637.00
TOTAL REFUND: $637.00
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: Date: /p/3�)/yr By: ,
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD SEWER CONNECTION PERMIT
11111 l` COMMUNITY DEVELOPMENT Permit#: SWR2014-00107
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/02/2014
Parcel: 1 S 135AB01004
Jurisdiction: Tigard
Site address: 10220 SW GREENBURG RD 250
Project: Sodexo Subdivision: METZGER,TOWN OF Lot: 9
Project Description: .13 EDU increase.
Contractor: Owner: LINCOLN CENTER LLC
BY SHORENSTEIN PROPERTIES LLC
555 CALIFORNIA ST 49TH FL
SAN FRANCISCO,CA 94104
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 10/02/2014 $637.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .13
Total $637.00
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. Tho ures 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 ailing 503.23. .r 1.800.332.2344.
Issued By: ` �,` , S Permittee Signature:`—C\ l__ ! roll-
sss1116`2
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.
llii Accumulative Sewer Tally
Tenant Name: Sodexo SWR# 2014-00107
Site Address: 10220 SW Grccnburg Rd#250 PLM# 2014-00328
Parcel#: 1S135AB01004
Fixture \ ,iln, I'rccunt' Previous Crcdirs Gapped Fixture l:ixture New New
due count , Treed #. . clue 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 I 0 0 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 0 0 0 0 0
-3 inch 5 0 II 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 HI') 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 I 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 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related _' 0 0 I 2 1 2
-Bradley - 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter I 0 0 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 1 2 1 2
Current Fixture Value 2 divided by 16= u.125 Current EDU 1 EDU= $4,900.00
Previous Fixture Value 0 divided by 16= _ 0.000 Previous EDU
Change 2 divided by 16= 0.125 over (under) S 637.00
Enter EDU Change Here 0.130
Notes: Per Becky with CWS,do not charge for the emergency only hub drain.
Authorized Name/Signature: Debbie.\damski Date: 10/2/2014
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\.S ewerTallySheet_49(N)._070114.xlsx