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Permit (21) City Of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V I 0 , . 4 114 Request for Permit Action .5-26/ip, TIC A R f) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: 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 tgf City Staff Check(✓)one REFUND OR Name: 1 INVOICE TO: (Business or Individual) / /ftJ Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): 4 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 #: rP5 .2-p ( (p-- 000gb Site Address or Parcel #: 1 a t q Q 6u.) ce-fA0-e,-A Adlty • idoisc›.- ' ( _ Subdivision Name: Lot#: EXPLANATION: ---1----Itic) I"""60- 6 -01Z —Dia_o_e_ 6.‘L...... ✓h s..0.6 , #.0J p_o_Aivix`_22— C oh H€. o1Le-oo 303 . Ci-EA-r�/� /P &72-0 , Signature: (I) - . Date: S/S�/0 Print Name: ---DO'y61q_ A-1./t-6-1-`DIA-11 Refund Policy 1. The city's Community Development Director,Building Official or City l nginecr 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. .AIl refunds will be returned to the original payer in the form of a check via VS postal service. 3. Please allow 3-4 weeks for processing refund requests. Route to Sys Admin: Date S y to B- Route to Records: Date 74. Ad, By Refund Processed: Date /9- B Invoice Processed: Date By Permit Canceled: Date 5/2.40//6 B, Parcel Tag Added: Date By I:A Building\Forms\RegPennitr\ction_I) 2314.diic Building Permit Application / • 2 - /co .+i. Fire Protection System , , FOIz OFFI( I.: I. sI:O\l.\ Received City of Tigard0 Date/By: /1 �y �� PennitNo.: t /1/6r-e(o��Q u 13125 SW Hall Blvd.,Tigard,OR 97 •. v Plan Review IIII Phone: 503.718.2439 Fax: 503.598.t1''.'0 2 ,7j16 Date/By: Other Permit: Inspection Line: 503.639.4175 Date Ready/By: .orris: I ® See Page 2 for 1 11;AItl) � Internet: www.tigard-or.gov �,i I ' d 1(,11,3 i 1 Notified/Method: Supplemental Information it F ❑New construction 0 Demolition Permit fees*are based on the value of the work performed. Indicate the value(rounded to the nearest dollar)of all ❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the r C`d►i$r Y OF 'PuJc itON work indicated on this application. ❑ 1-and 2-family dwelling Commercial/industrial Valuation: $ ❑Accessory building ❑\Multi-family Number of bedrooms: ❑Master builder 0 Other: Number of bathrooms: t ; OB SITE "INFORMATION AND LOCATION Total number of floors: / �j Job site address:1�/ ty� ,(./Y/, S T�j(j/y /4� New dwelling area: square feet City/State/ZIP:-7-76/f-,4 -6(�4 - J Garage/carport area: square feet Suite/bldg./apt.no.: Project name: i -jle/4�,,h16 Covered porch area: square feet Cross street/dire tions to job site: pp Deck area: square feet /2/. ... .- crztatee_ l�f 4 Other structure area: square feet ,., , i" `�A**4 At=USE C.Hg6( IST Subdivision: Lot no.: Permit fees*are based on the value of the work performed. Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all equipment,materials,labor,overhead,and the profit for the DESCRIPTION Ol~ WORK` work indicated on this application. Valuation: $ 2 4 deo, 00 Existing building area: square feet e7,r!/ e7 eio New building area: square feet — IPR I OWN R C � Number of stories: ' .,, 1.. ..� .. W „ _ s. Name: Type of construction: Address: Occupancy groups: City/State/ZIP: Existing: Phone:( ) Fax:( ) New: APPLICANT 0 COI ITACI' PE11 SON NOTI � Business name: All contractors and subcontractors are required to be Contact name: licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: jurisdiction in which work is being performed.If the City/State/ZIP: applicant is exempt from licensing,the following reasons apply: Phone:( ) Fax::( ) E-mail: —..:74,77-;:,17. NTRACTOR _49"::::''.:, '''''.',,,,l,'..,,..:,.,, , ':. '`,--;,:,,: ' iffijobING '( Rairt,40 Business name: lea' �j 4 �" - Q Ci ♦ . Permit fee: Address: / j. 1 &c. W o ��c State surcharge(12%of permit fee): rt4 City/State/ZIP: ,o S l� g - if FLS plan review(40%of permit fee): Phone:( )�® 6 2 Fax:( ) (Due upon application submittal.) CCB lic.: i �3 93 9 Total permit fees: Amount received: Authorized signature" 1 [%v This permit application expires if a permit is not obtained Print name: '77 41©7'-'y JOS♦ Date: 6 l/ 6-eZwithin 180 days after it has been accepted as complete. 1J * Fee methodology set by Tri-County Building Industry Service Board. h,Building,Permits FPS-PermitApp_031016.doc 440-4613T(11,02 COMWEB) N V C UQ N 0 0 C a O � o' O r� e••1• A CD A 1� ILI ❑ ❑ G O ': n G G O J lV W G1It O f�I Oa. crQ ►'?! rD �• �n iii �: Eli+3' n O rD rD rD w rD a o a . o y � o' CA r -n m n 4A -vq� h ,CD O rD a Z -o 1 o c _ cry ° � tom- cn� a G' rs cn o ,,o rD CD rD ITI cn El El El 1:1 rD � A cn El �1 (D `�° `�° CDID d C� 'ii ❑ ❑ h rD M- a�' G 0• �• p• o d W j rD wFD . �• cry �• „ ° ,a CD m rD a V C UQ N 0 0 C a O � o' O r� e••1• A CD A 1�