Permit (131) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
4 Request for Permit Action
IN
TI G A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223.503-718-2439 •www tigard-or.goc / 0 1
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TO: CITY OF TIGARD 0/4' 1 :,
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax 503-598-1960 TigardBuildingPermits®tigard-or.gov
FROM: ❑ Owner D Applicant [' 'Contractor ❑ City Staff
Check(a')one
REFUND OR Name:
INVOICE TO: (Business or Individual) 1 kc Pa{-Terson 1:71 un 15,ivi
Mailing Address: p p), Box 535-o
City/Saxe/zip: aLar 'on(, W 61/021
Phone No.: 603— 1,66"143 01,
PLEASE TAKE ACTION FOR THE TTEM(S) CHECKED(1):
CANCEL • Ill P ' APPLICATION.
2-(1 -FU . 1"a* I 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). ,r-y p
Permit#: �W,C,2045'-- 0d/,o O
Site Address or Parcel#: Ø6C0 S w 6pYL4 C8 cilli' O
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171a ) O(2 ai1223
Subdivision Name: J/a 17tj ele) Intl ' ? sA- Cinuotki
EXPLANATION: PextzyrylINLAh of cr/AY1 on el Oh 1
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Signature: 4n'rvtIj/l Date: 0312/ i 1 to
Pmt Name: J Ono t y q`r
1 cfund Pouh• Jc
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 vis US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
'oute tri-Si AMtnui: Tate By Route to 1tecorc s: Dale- _(' /G, Tri -4-7--
Refund
- -Refund Processed Date V/V/ B Invoice Processed: Date BY
Permit Canceled: Date 4//4/4, By, — ParcelTagAdded: Date By
I:\Building\Forms\RegPcrmitAction_o992314. oc
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•
TIGARD
City of Tigard
June 16, 2016
Japanese International Baptist Church
8500 SW Spruce St
Tigard, OR 97223
Re: Permit No. SWR2015-00168
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: 8500 SW Spruce St.
Project Name: Japanese International Baptist Church
Job No.: N/A
Refund: ® Check #221258 in the amount of$11,475.00.
❑ Credit card "return" receipt in the amount of$ .
❑ Trust account "deposit"receipt in the amount of$ .
Notes: Plumbing contractor reduced scope of work to underground plumbing only resulting
in a reduction of sewer connection fees. New sewer connection fees will be determined
when plumbing contractor applies for permit to set plumbing fixtures.
If you have any questions please contact me at 503.718.2430.
Sincerely,
o<S64.4zeiv_c___
Dianna Howse
Building Division Services Coordinator
Enc.
l:\Building\Refund 112iisSr o ale dvelpaTeigagi l01-egon 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 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: Japanese International Baptist Chkrcki DATE: 6/3/2016
8500 SW Spruce St DAY
Portland, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 400887 Case#: SWR2015-00168
Date: 12/3/2015 Address/Parcel: 8500 SW Spruce St
Pay Method: Check Project Name: Japanese International Baptist
Church
EXPLANATION: Plumbing contractor reduced scope of work to underground plumbing only resulting in
a reduction of sewer connection fees.
REFUND INFORMATION:
Fee Description From Receipt Revetttie Account NO. Rc.;10
Example: Building Permit Fee: Esample. . 300000-43104 `4S'A-InitIO4.;
Sewer Connection Fee 500-0000-25500 $11,475.00
TOTAL REFUND: $11,475.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager T k `
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/e//b By: L("
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD311
SEWER CONNECTION PERMIT
3 COMMUNITY DEVELOPMENT Permit#: SWR2015 00168
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/03/2015
Parcel: 1 S 136CB04400
Jurisdiction: TIGARD
Site address: 8500 SW SPRUCE ST
Project: Japanese International Baptist Church Subdivision: WEST PORTLAND HEIGHTS Lot: M
Project Description: .63 EDU CREDIT. 6/3/2016: REPRINT permit due to change in scope of work on PLM2015-00410. Sewer credit
for 1 EDU applied from BUP2015-00109.
Contractor: Owner: JAPANESE INTERNATIONAL BAPTIST C
8500 SW SPRUCE ST
PORTLAND, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics:
Type of Use: COM
Class of Work: NEW
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 3.25
Total $0.00
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. 32.1987 or 1.800.332.2344.
Issued By: Permittee Signature: QA/ /51-7'/oc./e 770"/
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
i Tenant Name:1111 " Japanese Intenational Baptist ChurchSWR# 2015-00168(VISED
Site Address: 8500 SW Spruce St PI,M# 2015-00410\\
TIGARD
Parcel#: 1S136CB04400
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 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 3 6 3 6
-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 IIP) 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 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-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 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 1 16
TOTALS 0 0 0 0 3 6 3 -10
Current Fixture Value -10 divided by 16= -0.625 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -10 divided by 16= -0.625 over (under) $ (3,213.00)
Enter EDU Change Here -0.630 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:Reduction in plumbing fixtures resulted in reduction of sewer EDU and a credit for this project and sewer permit is voided.
Authorized Name/Signature: Dianna I lowse Date: 6/3/2016
Building Division
sote: The property owner shall retain the ORIGINAL,sewer tally record. If credits exist,this document will serve as a voucher which must be
ubmitted to the City of Tigard Building Division to redeem credits towards future system development charges.
1:ABuilding\Sewer Tally\Sewer LallySheet_5100_070115.xlsx
Accumulative Sewer Tally
14i Tenant Name: Japanese Intonational Baptist ChurchSWR# 2015-00168 ra�.�
1lc_;AitI)
Site Address: 8500 SW Spruce St PLM# 2(115-00410
Parcel#: 1 S 136CB04400
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#5 value count added# added value total#s total values
Baptiscry/Font 4 0 0 0 0 0
Bath: -1'ub/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 4 0 0 0 0 0
-Domestic 2 0 0 0 0 0
Drinking fountain 1 0 0 1 1 1 1
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 3 6 3 6
-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 IIP) 16 0 0 0 0 0
-Commercial(to 5 IIP) 32 0 0 0 0 0
-Industrial(over 5 IIP) 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 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 6 12 6 12
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 1 3 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-"Toilet 6 0 0 4 24 4 24
Urinal 6 0 0 1 6 1 6
Previous 11DU Count 0 0
Capped I?DU Credit 1 16
'I'O7'.1LS 0 0 0 0 16 52 16 36
Current Fixture Value 36 divided by 16= 2.250 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous El)V
Change 36 divided by 16= 2.250 over (under) S 11,475.00
Enter EDU Change Here 2.250
'Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes: 1 EDU credit applied from BUP2015-00109.
Authorized Name/Signature: Debbie.ldamski Date: 12/3/2015
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:ABuilding\Scwcr Tally\Sewcr'TallvShcct_SI 11(1_10)115.xisx
""' fi{i;. CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENTli
Permit#: SWR2015-00168
°`. Date Issued: 12/03/2015
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1 S136CB04400
Jurisdiction: TIGARD
Site address: 8500 SW SPRUCE ST
Project: Japanese International Baptist Church Subdivision: WEST PORTLAND HEIGHTS Lot: M
Project Description: 2.25 EDU increase. Sewer credit for 1 EDU applied from BUP2015-00109.
Contractor: Owner: JAPANESE INTERNATIONAL BAPTIST C
8500 SW SPRUCE ST
PORTLAND, OR 97223
PHONE •
PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 12/03/2015 $11,475.00
Type of Use: COM
Class of Work: NEW
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 3.25
Total $11,475.00
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. ose rules a : set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions
to OU by calling 503.232. 987 •• 800.332.2344.
Is•ued By: / // I Permittee Signature: /r 4 Le„,
_..........1,4,
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
a "tenant Name: JaIPIIpanese Intonational Baptist Church SWR# 2015-00168
C . ,
Site Address: 8500 SW Spruce St PLM # 2015-00410
TIGA.RD
Parcel#: 1S136CB04400
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptisery/l:ont 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 4 0 0 0 0 0
-Domestic 2 0 00 0 0
Drinking fountain 1 0 0 1 1 1 1
Eve Wash 1 0 0 _ 0 0 0
Door Drain/Sink: -2 inch 2 0 0 3 6 3 6
-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
lee 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
Ree. 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 2 0 0 6 12 6 12
-Bradley 5 0 0 0 0 0
-Com/Sery/Util- Food Related 3 0 0 1 3 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-Toilet 6 0 0 4 24 4 24
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped E.DU Credit 1 16
TOTALS 0 0 0 0 16 52 16 36
Current Fixture Value 36 divided by 16= 2.250 Current EDU 1 EDU= $5,100.00
Previous fixture Value 0 divided by 16= 0.000 Previous EDU
Change 36 divided by 16= 2.250 over (under) S 11,475.00
Enter EDU Change Here 2.250 '' ,
-'Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in .0 I 4 or less shall be rounded down to.0I.
Notes: I EDU credit applied from BUP2015-00109.
Authorized Name/Signature: Debbie Adamski Date: 12/3/2015
Building Division
Note: The property owner shall retain the ORIGINAL.sewer tally record. I f credits exist,this document will serve as a voucher which must be
submitted to the Ciry of Tigard Building Division to redeem credits towards future system development charges.
1:ABuilding\Soyer Tally\Scwcr'IallvSheet_5II IU_117(11 I 5.xlsx