Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTME> ECEIVED
Request for Permit Action
APR 8 2015
1 :k ;A I; 1 , 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
BIT/ Or TIOnnD
BUILDING DIVISION
TO: CITY OF TIGARD
Building Division 0 t
13125 SW Hall Blvd.,Tigard,OR 97223 V
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov S/?
FROM: j Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Fill7 is ` 5,c4,.....0.2.,/0z 't
Mailing Address: 9 ZQ � keA/ -4'A t.,&
City/State/Zip: 7;Ai.0 9 22
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
51 CANCEL/VOID PERMIT APPLICATION.
'NO 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#: glC z1>,6--0oIQb
Site Address or Parcel#: ?72D 6w' f 'LA 4i
Project Name: ?4r- u� r 7L74-
Subdivision Name: Lot#:
EXPLANATION: 1,j),,,a_k.. —1- t E t_1,_\;-c- f cL'11 K O,8 Ui'E ,
Signature: /J j,j _1 ..,/�. I Date: 4" C /
Print Name: A4r iz fr. 0, S e Al,//7"-
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 56, /4? yy• 9 y _ "7' '2 V
(. 7y 57 39 A 3S
r ' 1
642. 9x- So, 33 /A.59
FOR OFFICE USE ONLY
Route to S s Admin: Date 4' A 1/Mill11/21PP.1M Route to Records: AMM B 407:1 I
Refund Processed: Date P 'ri Invoice Processed: Date By
Permit Canceled: Date 0923 B _,f♦� '. cel Tag Added: Date By
Forms 1 .doc
. n
TIGARD
City of Tigard
May 7, 2015
Patrick Schmitt
9720 SW 74th Ave.
Tigard, OR 97223
Re: Permit No. ELC2015-00196
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9720 SW 746 Ave.
Project Name: Schmitt
Job No.: N/A
Refund Method: ® Check#217326 in the amount of$50.33.
❑ Credit card"return" receipt in the amount of$ .
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 minor label was used. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
„a„
_ ---i_e_____
4 lr
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
ErCity 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 Requestjbr 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: Patrick Schmitt DATE: 4/30/2015
9720 SW 74th Ave
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 200053 Case#: ELC2015-00196
Date: 3/31/2015 Address/Parcel: 9720 SW 74±Ave.
Pay Method: CreditCard Project Name: Schmitt
•
EXPLANATION: Per applicant's request as work was done under a minor label. Refund 80%o of permit
fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $44.94
12% State Surcharge 100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SIGNATU .ES/DATE:
If under$5,000 Professional Staff /( r ?,-��
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: I Date: _ j`j//.s By.
I:\Building\Refunds\RefundReguest.doc x 09/01/2010
n CITY OF TIGARD ELECTRICAL PERMIT
COMMUNITY DEVELOPMENT Permit#: ELC2015-00196
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/31/2015
Parcel: 1 S 125DC00201
Jurisdiction: Tigard
Site address: 9720 SW 74TH AVE
Project: SCHMITT Subdivision: BOULEVARD HEIGHTS Lot: 26
Project Description: (1)branch circuit for furnace replacement.
Contractor: OWNER Owner: SCHMITT, PATRICK D& PATRICIA J
PATRICK SCHMITT 9720 SW 74TH AVE
9720 SW 72ND AVE TIGARD,OR 97223
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 03/31/2015 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 03/31/2015 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
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 nter. Those rules re set faith in OAR
952-001-0010 through OAR 952-001-0090. You may ob n a copy oTthq rules or direct questions to OUNC by calling 503.2 987 or 1.800.332.234
Issued By: Perm ittee Signature:
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 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.
Electrical Permit Application t o 1t()1 1 1( 1 1 1 (l\l 1
City of Tigard 4, 1{ ( ; " Received
•111111 13125 SW Hall Blvd.,Tigard,OR MAYA,1 1-14 Plaan Review® . c`� _ r
I Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Related Permit 4:
Inspection Line: 503.639.4175 Ready Date/By: HI See Page 2 for
I It. N I:I) Internet: www.tigard-or.gov MAR 3 1 2015 Notified/Method: Supplemental Information
OF WORK (��i PLAN REVIEW
❑New construction Addition/alterat}Od/f 18�ement"n�L Please check all that apply(submit 1 sets of plans w/items checked):
❑ ,.. ��NC DIVISION ❑Service or feeder 400 amps or more ❑Building over three stones.
Demolition 0 1 where the available fault current ❑Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or ❑Floating buildings.
0 1 and 2-family dwelling ❑Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 ❑Commercial-use agricultural
amps for all other installations. buildings.
❑Multi-family ❑Master builder ❑Other: ❑Fire pump. ❑Installation of 150 KVA or
JOB SITE INFORMATION AND LOCATION ❑Emergency system. larger separately derived
.7 I 7 ,4 I,�_ ❑Addition of new motor load of system.
7bJob#: Job site address: ✓S IoOHP or more. ❑"A","E","1-2","1-3",
City/State/ZIP: �_� n n J�J ❑Six or more residential units. occupancy.
1 i 6.1GIJ i �G c7!r L.g ❑Health-care facilities. ❑Recreational vehicle parks.
Suite/bldg./apt.#: 4 Project name: ❑Hazardous locations. ❑Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: / C:C ,i.../ 1---- FEE SCHEDULE r
Description I Qty. I Each 1 Total I •
New residential single-or multi-family dwelling unit.
Subdivision: Lot 4: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#:
Ea.add'1500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK
` Limited energy,residential 75.00 2
��1('4 ee IZAG/r—///�� (with above, lti
GI Limited energy,multi-family 75.00 2
,., residential(with above sq.ft.)
Re
E/ROPERTY OWNER I ❑ TENANT
Renewable Energy ❑ See Page 2
Services or feeders installation,alteration,and/or relocation
Name: F alb „1.* 71-71--- 200 amps or less 100.70 2
Address: 1VD �K �/4�v 201 amps to 400 amps 133.56 2
s 401 amps to 600 amps 200.34 2
City/State/ZIP: 1}( �( Q,n b 9.9z z 601 amps to 1,000 amps 301.04 2
Phone:` zz9zfJ lam^-EiSFJt 1?,2 Fax:( ) J Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email:
relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,leas r nt,or exchange,accor�t' to ORS 4' ,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: / _ '! / ///� Dates 401 amps to 599 amps 168.54 2
❑ APPLICANT • CONTACT Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
Business name: above service or feeder fee,
each branch circuit 7.42 2
Contact nom C L / ! B.Fee for branch circuits without ,
✓�� service or feeder fee,first r 56.18 �i.ld 2
Address: branch circuit
City/State/ZIP: `//' 40 79223 Each add'l branch circuit 7.42 2
t� Miscellaneous(service or feeder not included)
Phone: vf Fax: :( ) Each manufactured or modular
7 ����....7777 dwelling,service and/or feeder 67.84 2
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: Sign or outline lighting 67.84 2
Address: Signal circuit(s)or limited-energy El See Page 2 2
panel,alteration,or extension.
City/State/ZIP: Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 66.25/hr
Email: Industrial plant(1 hr min) 78.18/hr
Inspections for which no fee is 90.00/hr
CCB Lic.: Electrical Lie.: Suprv.Lie.: specifically listed(%z hr mm)
ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal: 57, .I y
Print name: r_�.,.sa 1. _- — - - Date: ❑Plan Review Required(25%of permit fee):
ttis ""� mow,"- "" �/� State surcharge(12%of permit fee): , -7LI
Authorized sign�ure: TOTAL PERMIT FEE: _!t'.i,
/�/ ` This permit application expires if a permit is not obtained within 180
Print name: /:�W/Fl / /Mil Date: .f AW days after it has been accepted as complete.
• Number of inspections allowed per permit.
I:\Building\Pmnits\ELC_PennitApp_ELR_ERE.doc Rev 04/21/2014 440-4615 11/05/COM/wEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
Fee for all residential systems combined: $75.00
Description I Qty. I Each I T ,1 I •
�' Renewable electrical energy systems:
Check Type of Work Involved: 5 kvaorless 100.70 2
5.01 to 15 kva 133.56 2
n Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
I I Burglar Alarm 25.01 to 50 kva 301.04 2
I Garage Door Opener* 50.01 to 100 kva 552.26 - 2
>100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
n Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 7.42 3
TI Vacuum Systems* >100 kva—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr 1
charged at an hourly(1 hr min)
Inspections for which no fee is 90.00/hr
specifically listed(1/hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system:ONLY:
$75.00 Number of inspections allowed per pennrlon Page 1):t.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
n Boiler Controls
n Clock Systems
I Data Telecommunication Installation
I I Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I1Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 04/21/2014