The URL can be used to link to this page

Permit (64) CITY OF TIGARD MASTER PERMIT N .#' COMMUNITY DEVELOPMENT Permit#: MST2015-00069 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 • , ( Date Issued: 06/06/2016 T[t�.`t .0 9 It. ;' Parcel: 1S134CB02300 FAN= Jurisdiction: Tigard Site address: 12235 SW SUMMER CREST DR Subdivision: SUMMER HILLS PARK Lot: 14 Project: Adams Project Description: 105 sf addition to master bedroom BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 105 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Total: 105 sf Value: $20,000.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 0 Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Other Fixtures: 0 Drywall-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel Types Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add'I 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 1 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 601+amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ACS SF VB R-3 105 Owner: Contractor: ADAMS,DOUGLAS ALAN&TAMMY DEUDAVID GREEN CONSTRUCTION LLC Required Items and Reports(Conditions) 12235 SW SUMMER CREST DR 29100 SW BURKHALTER RD TIGARD,OR 97223 HILLSBORO,OR 97123 PHONE: PHONE: 503-648-9805 FAX: 503-648-7018 Total Fees: $1,104.96 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+ rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. obtain a c•.•o the ru- •r direct questions to OUNC by c• • 03.232.1 9'37 or 1.800 2.2344. Issued By: r 411 e Signature: ') �) r C C. 03.639.4175 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. CITY OF TIGARD MASTER PERMIT 1 3 �� COMMUNITY DEVELOPMENT Permit#: MST2015-00069 Date Issued: 06/06/2016 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 1S134CB02300 Jurisdiction: Tigard Site address: 12235 SW SUMMER CREST DR Subdivision: SUMMER HILLS PARK Lot: 14 Project: Adams Project Description: 105 sf addition to master bedroom BUILDING Floor Areas Required Setbacks Required Stories: 0 Bedrooms: 0 First: 105 sf Basement: 0 sf Left: 0 Parking Spaces: 0 Height: 0 Bathrooms: 0 Second: 0 sf Garage: 0 sf Front: 0 Smoke Dwelling Units: 0 Third: 0 sf Right: 0 Detectors: Total: 105 sf Value: $20,000.00 Rear: 0 PLUMBING Sinks: 0 Water Closets: 0 Washing Mach: 0 Laundry Trays: 0 Rain Drain: 0 Urinals: 0 Lavatories: 0 Dishwashers: 0 Floor Drains: 0 Sewer Lines: 0 SF Rain Storm Sewer: 0 Tubs/Showers: 0 Garbage Disp: 0 Water Heaters: 0 Water Lines: 0 Drains: Catch Basins: 0 Bckflw Prevntr: 0 Footing Drain: 0 Ice Maker: 0 Hose Bib: 0 Backwater Value: 0 Other Fixtures: 0 Drywell-Trench Drain: 0 Other Fixture Units: MECHANICAL Fuel TYPOS Air Conditioning: N Vent Fans: 0 Clothes Dryers: 0 Heat Pump: N Hoods: 0 Other Units: 0 Furn<100K: 0 Vents: 0 Woodstoves: 0 Gas Outlets: 0 Furn>=100K: 0 ELECTRICAL Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits 1000 sf or less: 0 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0 Ea add'l 500 sf: 0 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 1 Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0 601-1000 amp: 0 6014-amp-1000v: 0 1000+amp/volt: 0 ELECTRICAL-RESTRICTED ENERGY SF Residential Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All Other: N Other Description: Ecompasing: N BUILDING INFO Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet: ACS SF VB R-3 105 Owner: Contractor: ADAMS,DOUGLAS ALAN&TAMMY DELPHILEO CONSTRUCTION Required Items and Reports(Conditions) 12235 SW SUMMER CREST DR 13155 SW WORCHESTER PL TIGARD,OR 97223 TIGARD,OR 97223 PHONE: PHONE: 503-830-5827 FAX: Total Fees: $959.16 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 Cent= T ose rules are set forth in OAR 952-001-0010 through OAR 952-001- 090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1•: or 1 :00.332.23.4.r Issued By: Permittee Signature: 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 Pert `A .1if�{ > City of Tigard P Received Date/By: Permit#: 13125 SW Hall Blvd.,Tigard,OR 972231 1 i Plan Review Related Permit#: Phone: 503.718.2439 Fax: 503.598.1960'N 2016 Date/By: Inspection Line: 503.639.4175 Ready Date/By: Juris ® See Page 2 for TIGARD Internet: www.tigard-or.gov CITY Y OF FIGARD Notified/Method: Supplemental Information BUILDING DIWTSIQN TYPE OF WORK ❑New construction ❑Addition/alteration/replacement ❑Demolition ❑Other: CATEGORY OF CONSTRUCTION ❑ 1-and 2-family dwelling ❑Commercial/industrial ❑Accessory building ❑Multi-family ❑ Master builder ❑Other: JOB SITE INFORMATION AND LOCATION Job#: Job site address: City/State/ZIP: Suite/bldg./apt.4: Project name: Cross street/directions to job site: Subdivision: Lot#: Tax map/parcel 4: DESCRIPTION OF WORK ❑ PROPERTY OWNER ❑ TENANT Name: Address: City/State/ZIP: Phone:0 Fax:() Email: Owner installation: This installation is being made on property that I own which is not intended for sale, lease,rent,or exchange,according to ORS 447,449,670,and 701. Owner signature: Date: 0 APPLICANT 0 CONTACT PERSON Business name: Contact name: Address: City/State/ZIP: Phone:0 Fax: :0 Email: CONTRACTOR Business name: western cascade electric Address: P.O.Box 23124 City/State/ZIP: Tigard Oregon 97281 Phone:O 503-504-2815 Fax:0 503-746-6962 Email:wcejevans@gmail.com Lic.: 153416 i l) n r Electrical Lie.: 34-616C Suprv.Lic.: 4625S Suprv.Electrician signature,required: � Print name: Jeff Evans Da'fe: Authorized signature: Y .ta ❑Service or feeder 400 amps or more 0 Building over three stories. where the available fault current 0 Marinas and boatyards. exceeds 10,000 amps at 150 volts or 0 Floating buildings. less to ground,or exceeds 14,000 0 Commercial-use agricultural amps for all other installations. buildings. ❑Fire pump. 0 Installation of 150 KVA or ❑Emergency system. larger separately derived ❑Addition of new motor load of system. 100HP or more. ❑"A" "E" "1-2" "1-3" ❑Six or more residential units. occupancy. ❑Health-care facilities. 0 Recreational vehicle parks. ❑Hazardous locations. 0 Supply voltage for more than ❑Service or feeder 600 amps or more. 600 volts nominal. FEE SCHEDULE Description I Qty. I Each I Total I " New residential single-or multi-family dwelling unit. Includes attached garage. 1,000 sq.ft.or less 168.54 4 Ea.add'!500 sq.ft.or portion 33.92 1 Limited energy,residential 75.00 2 (with above sq.ft.) Limited energy,multi-family 75.00 2 residential(with above sq.ft.) Renewable Energy 0 See Page 2 Services or feeders installation,alteration,and/or relocation 200 amps or less 100.70 2 201 amps to 400 amps 133.56 2 401 amps to 600 amps 200.34 2 601 amps to 1,000 amps 301.04 2 Over 1,000 amps or volts 552.26 2 Temporary services or feeders installation,alteration,and/or relocation 200 amps or less 59.36 1 201 amps to 400 amps 125.08 2 401 amps to 599 amps 168.54 2 Branch circuits—new,alteration,or extension,per panel A.Fee for branch circuits with above service or feeder fee, 7 42 2 each branch circuit B.Fee for branch circuits without service or feeder fee,first 56.18 2 branch circuit Each add'I branch circuit 7.42 2 Miscellaneous(service or feeder not included) Each manufactured or modular 67.84 2 dwelling,service and/or feeder Reconnect only 67.84 2 Pump or irrigation circle 67.84 2 Sign or outline lighting 67.84 2 Signal circuit(s)or limited-energy 0 See Page 2 2 panel,alteration,or extension. Each additional inspection over allowable in any of the above Additional inspection(1 hr min) 66.25/hr Investigation(I hr min) 90.00/hr Industrial plant(I hr min) 78.18/hr Inspections for which no fee is 90.00/hr specifically listed(V2 hr min) ELECTRICAL PERMIT FEES Subtotal: ❑Plan Review Required(25%of permit fee): State surcharge(12%of permit fee): TOTAL PERMIT FEE: This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. • Number of inspections allowed per pennit. I:\Building\Permits\ELC_PermitApp_ELR_ERE.doc Rev 06/17/2015 V City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT ■ Building Permit Review — Residential TIGARD Building Permit #: i'11 51-a-0 i 5-000607 Site Address: 12235 SW Summl'f C br. Project Name: Ma ry)S 4- Lot #: (New dwelling=subdivision name;Addition or Alteration=last name of owner) Planning Review Proposal: 1-3 x `1 a&8\*iof, +O ST \oma 14cVerify site address/suite# exists and active in permit syste . ' River Terrace Plan District: ❑ Yes t'No Siy Plan Elements: ricisting ree(3)copies of site plan structures on site e plan must be on 8-1/2"x 11"or 11 x 17"paper otprint of new structure(including decks)with finished Zr P rawn to scale(standard architect or engineer scale) floor elevations 0, •rth arrow --BIItility locations(required for new,may apply for additions) address,project or subdivision name and lot number —ocation of wells/septic.Urpplicant information(name and phone number) $Erosion control(including drainage-way protection,silt fence MLot dimensions and building setback dimensions design,location of catch basin,etc.) -$tot area,building coverage area,percentage of coverage and tiStreet names pervious area(applicable if R-7,R-12,R-25&R-40) Street tree size,type and location Property corner elevations(2 foot contour lines if more than .xisting trees to be retained with drip line,and tree 4/foot differential) protection measures Vi Clean Water ervices-Service Provider Letter(lot platted prior to 9/10/1995): /Required: Yes,applicant was notified ❑ No Received: Yes El No Ed Public Facilities Improvement(PFI) Permit: / Required: ❑ Yes,applicant was notified i" No Applied For: ❑ Yes ❑ No,stop intake • ---E-/Land Use Case#: • �f Zoning: R- L ,5 NJ Setbacks: Front 201 Rear 15' Side 5� Street Side — Garage 20' $Landscape Requirement: -Et-/Lot Coverage Maximum: ®/Building Height: Maximum Height 30 Actual Height .:t: 11'61) -E-Visual Clearance -9' asements LYJ Sensitive Lands: ❑ Yes ENo Type $Urban Forestry Plan -Et-Conditions "Met"prior to issuance of building permit Notes: Approved By Planning: L. CCv:.,— ---• Date: 5-7 - i S Revisions (after Building Submittal only) Reviewer Date Revision 1: 0 Approved ❑ Not Approved Revision 2: 0 Approved 0 Not Approved Revision 3: 0 Approved 0 Not Approved I:\Building\Forms\BldgPermitRvw_RES_031015.docx Building Permit Submittal Original Submittal Date: 6/7//S' Site Plans: # 0 5 Building Plans: # Building Permit#: Enter building permit#above. Workflow Routing: E Planning R Engineering 0--Permit Coordinator .12-13uilding Workflow Sign-off: a"Sign-off for Planning(include notes from planning review) Route Application Documents: [-Engineering: (1) copy of permit application, (1) site plan, (1) building plan and original plan review routing form. Building: original permit application, site plans,building plans,engineer and beam calculations and trust details,if applicable,etc. Notes: By Permit Technician: C Date: C/7//5� Engineering Review lope at building pad: 2 64 Conditions "Met"prior to issuance of building permit 0-Easements (encroachments)per engineering conditions of approval and plat ❑'"'(later Quality/Quantity Facility: Assess Water Quality Fee in-lieu: ❑ Yes [ No Assess Water Quantity Fee in-lieu: ❑ Yes a No LIDA Facility on lot: ❑ Yes ❑ NOT Approved by Engineering: Date: Notes: Approved by Engineering: 5�� Date: s _ic Revisions (after Building Submittal only) Reviewer Date Revision 1: ❑ Approved ❑ Not Approved Revision 2: ❑ Approved ❑ Not Approved Revision 3: ❑ Approved ❑ Not Approved Permit Coordinator Review ❑ Conditions "Met"prior to issuance of building permit ❑ Approved,NOT Released: Date: Notes: Revisions (after Building Submittal only) Revision Notice 1: Date Sent to Applicant: Revision Notice 2: Date Sent to Applicant: Revision Notice 3: Date Sent to Applicant: OK to Issue Permit Approved by Permit Coordinator: at* Q - C,:u Date: 5-11 - IS I:\Building\Forms\BldgPermitRvw_RES_031015.docx RECTI I V VP �� Clean Water Services File Number MAY 15-001338 CleanWater Services CITY U1' 1-11 V Sensitive Area Pre-Screening Site Assessment MIMING DIV1�� 1. Jurisdiction: Tigard 2. Property Information (example 1S234AB01400) 3. Owner Information Tax lot ID(s): 1S134CB02300Name: Doug and Tammy adams Company: Address: 12235 SW summer crest drive Site Address: 12235 SW summer crest drive City, State,Zip: Tigard,or 97223 City, State. Zip: Tigard,or 97223 Phone/Fax: Nearest Cross Street: E-Mail. 4. Development Activity (check all that apply) 5. Applicant Information A Addition to Single Family Residence(rooms,deck,garage) Name: Michael do ❑ Lot Line Adjustment U Minor Land Partition Company: Phileo construction ❑ Residential Condominium U Commercial Condominium Address: ❑ Residential Subdivision U Commercial Subdivision ❑ Single Lot Commercial ❑ Multi Lot Commercial City, State, Zip: Other Phone/Fax: 5038305827 E-Mail: Phileoconstruction@yahoo.com 6. Will the project involve any off-site work? ❑Yes lej No U Unknown Location and description of off-site work 7. Additional comments or information that may be needed to understand your project Addition to master bedroom 15'x7' This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands andlor Department of the Army COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law. By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate. Print/Type Name Michael do Print/Type Title ONLINE SUBMITTAL Date 5/6/2015 FOR DISTRICT USE ONLY ❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may also be required. ❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,State,and federal law. ❑ Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law. ❑ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached. ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. Reviewed by Date 5/7/15 2550 SW Hillsboro Highway • Hillsboro.Oregon 97123 • Phone: (503)681-5100 • Fax:(503)681-4439 • www.cleanwaterservices.org • tat Ireal' .. 4t. Sal "37Vig ‘144°1 NV-7c l . j / ' lupktie , :s„,,,,, tA)(, .. (-4 foorMaif 177 as#I ss c,« crs ar+ahw►illkW MOM MOM,'r•rr 1t ( iS v/ S 4s .i oo r O NO9310 dO aLV.L6 . _ x 1::,,R,2.5rrHSyc-y1 r".1-1-IO —+ 1 - v710/9 dO X1.11 7-t7£ r S/ 'ON CfVW - . r ^czZ Jai.XVI S'i7-Z1 479n►Ir0Z ` • I Iactslots maw° D W mos c"0./0/ -3.--jj a a Ts Km W MHO SOO=3 -a31`x30 t 5-0-8/ ( , 0 111*,610 WOG) w • 3SfiNINN FT; ; .f.. �L'i gr "W . N vaaa d IRS -* A f .. 5 . _, _ r 4 1 .f '! _.- -S_S '31.a' 1 -tp , o t i :N 1 3re�ld ,`.4:` AO A. . 2 zZZL.. rN`',c ?,ri../0 cr7f�H'91/- - WOW ' Mit ' , 'Sr)Iva . .1• -z',IN/"-I r'''5. rf'c> ,°S• `. t. i ,lirgrA-4/ .. .4 VA 3S111110 1 Of ' ' N.3N17O Pr i • • '70 ;7 ?P-J(A)W05--- c-c' 52Z1' :1 3roNd • --i FOR OFFICE USE ONLY—SITE ADDRESS: This form is recognized by most building departments in the Tri-County area for transmitting information. Please complete this form when submitting information for plan review responses and revisions. This form and the information it provides helps the review process and response to your project. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 11 . Transmittal Letter T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov TO: !�L/ DATE RECEIVED: DEPT: BUILDING DIVISION RECE V MAY 11 2015 FROM: iWk ,A1 Oa COMPANY: kp\ ix..ya� Cov\snLvCgib tlL1Gp[NG�F Di l RD PHONE: SO3. 33o .S 2'' jBy.f'%) RE: 17_ 3 Sw 5 y,v 'L Gc--c.,0- 0 2. `Li s7:,41) I5 "(1-106 9 (Site Address) t um er) Project name or subdivision name and lot number) ATTACHED ARE THE FOLLOWING ITEMS: Copies: Description: Copies: Description: Additional set(s) of plans. Revisions: Cross section(s) and details. Wall bracing and/or lateral analysis. 3xFloor/roof framing. Basement and retaining walls. Beam calculations. Engineer's calculations. Other(explain): REMARKS: 12/U„, s y e ft .1'l h (=Look r 4 at. ►O►.-v- 51-1,5 w5 1 s I / Ike L Yin FOR OF?ICE USE ONLY Routed to Permit Technician: Date: 1 (<; Initials: Fees Due: ❑ Yes [ N Fee Description: Amount ue: $ Special Instructions: _Reprint Permit(per PE): ❑ Yes ❑No ❑ Done Applicant Notified: Date: Initials: L\Building\Forms\TransmittalLetter-Revisions.doc 05/25/2012 City of Tigard . COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action TI G A;R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • �anu-'��4\� 4 . JUL 9 2018 TO: CITY OF TIGARD Building Division CITY OF nAd..G 13125 SW Hall Blvd.,Tigard,OR 97223 BUILDING 1LDI G D$"`ri 'fni,` Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: X Owner ❑ Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ 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#: MS 20 (S .- 0 bO(P 7 Site Address or Parcel#: 12-7-5S-- 5 W Stirs v -t,/e-I't.5(- UK Project Name: 44/kis Subdivision Name: Lot#: EXPLANATIO Cthn,-r etth,-y- vI.- &,,,,,,d V &I-- 0-tit- (4- ad i S _ WI lAt t COM 44-e. doh. Signature: " ,A+.1.9--,- Date: It/If S Print Name: ' b_______ _ILVA2,.&____AlAtAkok d 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. Route to Sys Admin: Date By Route to Records: Date By Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_092314.doc