Permit (39) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
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Request for Permit Action //f7//4 rw~
TIGARD 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 (�]C City Staff
Check(✓)one
REFUND OR Name: r �
INVOICE TO: (Business or Individual) k et _. — � � ,;` ,
Mailing Address: 90 9 5 04_0 v\ir)A-W
City/State/Zip: l Q Ole c1-7
Phone No.: 1563 - 9.9 as
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Et 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#: APs .c l Lo - 60 177
Site Address or Parcel#: ✓ ( �Dj .e_eQ wak L. /05'
Project Name:
Subdivision Name: Lot#:
EXPLANATION: ��,� ._A&2t}p_A ) (A361,L.
Signature: Date: 1r/3//6
Print Name: [Dry 0 ,Fc -f ASP- l
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date // 3 I& ?, WW Route to Records: Date it /, p B
Refund Processed: Date it//k %pi Invoice Processed: Date By
Permit Canceled: Date //17//4, By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092414..oc
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TIGARD
City of Tigard
November 14,2016
Wyatt Fire Protection
9095 SW Burnham St.
Tigard, OR 97223
Re: Permit No. FPS2016-00177
•
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 6650 SW Redwood Ln., #105
Project Name: Middlegate
Job No.: N/A
Refund Method: ® Check#222947 in the amount of$45.77.
❑ Credit card"return"receipt in the amount of$ .
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): Work was not performed in this suite. Void permit and refund 80% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
!•r'
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
II ell
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: Wyatt Fire Protection DATE: 11/7/2016
9095 SW Burnham St
Tigard, OR 97223 REQUESTED BY: Dianna Howse
DA
TRANSACTION INFORMATION:
Receipt#: 406778 Case#: FPS2016-00177
Date: 10/12/2016 Address/Parcel: 6650 SW Redwood Ln,#105
Pay Method: Check Project Name: Middlegate
EXPLANATION: Per applicant's request as work was not done in this suite and inspection called by
mistake. Ok to void/permit and refund 80%of permit fees per building official.
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Fee--D�scri�i 1 l € 1'rc�1leC � k+` s` F ��;h 'P �,'.'e�� �
3 5
Fire protection permit _230-0000-43104 $40.87
12%State Surcharge 100-0000-24001 4.90
TOTAL REFUND: $45.77
APPROVALS: SIGN ES 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 ADMINISTRATIONI SE.O%
Case Refund Processed: Date: //,/�j/ By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
2; ' COMMUNITY DEVELOPMENT Permit#: FPS2016-00177
Tit\RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/12/2016
Parcel: 2S112DA01400
Jurisdiction: Tigard
Site address: 6650 SW REDWOOD LN 105
Project: Middlegate Subdivision: 1996-048 PARTITION PLAT Lot: 2
Project Description: Adding(1)sprinkler head for TI. Affidavit submitted.
Contractor: WYATT FIRE PROTECTION INC. Owner: PACIFIC REALTY ASSOCIATES
9095 SW BURNHAM ATTN: N PIVEN
TIGARD, OR 97223 15350 SW SEQUOIA PKWY#300
PORTLAND, OR 97224
PHONE: 503-684-2928 PHONE:
FAX: 503-684-9657
FEES
Description Date Amount
Specifics: Permit Fee-COM 10/12/2016 $51.09
12%State Surcharge-Building 10/12/2016 $6.13
Type of Use: COM Plan Review-Fire Life Safety-COM 10/12/2016 $20.44
Class of Work: ALT Type of Const: Info Process/Archiving-Sm$0.50(up to 10/12/2016
Occupancy Grp: Height: ft 11x17) $0.50
Stories:
Commercial Sprinkler System:
Sprinkler Required: Yes Sprinkler Type: Wet
Standpipe Required: No Hazard: LT
Density: .10 Design Area: 1500
K Factor: 5.6
Commercial Fire Alarm System:
Fire Alarm Required: Yes Alarm Type:
Pull Station Required: Smoke Detectors Req:
Battery Calcs Provided: Cut Sheets Required:
Total $78.16
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $405.00
Residential Square Footage: 0
Fire Alarm Valuation: $0.00
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 503.232.1987 or 1.;u 32.2344.
Issued By: / Permittee Signature:
Cal '3.639.4175 by 7:00 a.m.for the next available inspec n date.
This permit card shall be kept in a conspicuous place on the job site until completion o , . oject.
Approved plans are required on the job site at the time of each inspection.
Building Permit Application
Fire Protection System FOR OFFICE USE ONLI'
City of Tigard 1 - Received if r
Date/B . �? *) Permit No.: J L .
13125 SW Hall Blvd.,Tigard,OR 972 ►7
Phone: 503.718.2439 Fax: 503.598.106 Plan Review
y Date/By:1111
Other Permit:
TI G A R D Inspection Line: 503.639.4175 1
Date Ready/By: El See Page 2 for
Internet: www.tigard-or.gov \ Notified/Method: f' Supplemental Information
❑New construction ❑ Iltkn Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
®Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
C. `' ", , 0 t . 1 work indicated on this application.
❑ 1-and 2-family dwelling ®Commercial/industrial Valuation: $
❑Accessory building 0 Multi-family Number of bedrooms:
❑Master builder 0 Other: Number of bathrooms:
.. FIIAou•'o 0 4 Total number of floors:
Job site address:6650 SW REDWOOD LANE New dwelling area: square feet
City/State/ZIP:PORTLAND,OR 97224 Garage/carport area: square feet
Suite/bldg./apt.no.:105 Project name:MIDDLEGATE RELOCATION Covered porch area: square feet
Cross street/directions to job site:
Deck area: square feet
Other structure area: square feet
81* ERC , S `C F
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
'. *. ':. I i• - F a ';
work indicated on this application.
ADD(1)FIRE SPRINKLER HEAD AS REQUIRED FOR TI Valuation: $$405.00
Existing building area: square feet
t ` , New building area: 0 square feet
*Q
E1 . . " `
. �; � k ,.� Number of stories: 1
Name:
Type of construction:
Address:
Occupancy groups:
City/State/ZIP:
Existing: LIGHT
Phone:( ) Fax ( )
New: ''
1_ ,71 . LICA'fl , ': •itOIyTAC' PERSON '
. - NOTYC
Business name:Wyatt Fire Protection
All contractors and subcontractors are required to be
Contact name:Max Colley licensed with the Oregon Construction Contractors Board
Address:9095 SW Burnham Rd under ORS 701 and may be required to be licensed in the
jurisdiction in which work is being performed.If the
City/State/ZIP:Tigard,OR 97223 applicant is exempt from licensing,the following reasons
Phone:(503)684-2928 Fax:: apply:
E-mail:m.colley@wyattfire.com
74 CoNTitA TOR ,.
" .sem ft.f A 0 Rini:0RIPPERMIT FE1
Business name:Wyatt Fire Protectionle 0 . .. (*rise �`.�', tu� ,
Address: Permit fee:
City/State/ZIP: State surcharge(12%of permit fee):
FLS plan review(40%of permit fee):
Phone:( ) Fax:( )
(Due upon application.)
CCB lic.:64077 Total permit fees: r: its
Authorized signature/ Amount received:
This permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
Print name:Max Colley Date:10/12/16
* Fee methodology set by Tri-County Building Industry
Service Board
I:\Building\Peimits\FPS-PefmitApp.doc Rev 01/05/2012
440-4613T(11/02/COM/WEB)
City of Tigard: Fire Protection Permit Checklist
Page 2-Supplemental Information
1.) El New 2.) Modification to sprinkler heads only:
❑ Addition ® 1-10 heads: No plan review required.
® Alteration ❑ 11+ heads: Plan review required.
❑ Repair
Number of sprinkler heads: 1
Additional description of work:
SYWOhitil,ete>t1 �a PAs pP cib e I
ca e ial S n : * •, ,;
Wet ❑ Dry
Additional Standpipes 0
Information: Hazard Group LIGHT
Density 0.10
Design Area 1500
K. Factor 5.6
Sprinkler Project Valuation: $ 405
* YF.. Hood $7uPpre` s> Ssem
Hood Project Valuation: I $
. ,' `',Yom' .e
Submittal shall Battery Calculations LI Yes
include: Individual Component ❑ Yes
Cut Sheets
Fire Alarm Project Valuation: $
per` eostis o m v
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39 t w ‘
Sprinkler Project Square Footage: sq. ft.
Project valuation subtotal (see A,B &C above): $
Permit fee based on project valuation(see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12%of permit fee): $
FLS Plan Review (40%of permit fee): $
TOTAL: $
Plan review requires a completed application and three (3) sets of plans at submittal.
Plan review fees are required at submittal.
W:\Max\1112 PERMIT APPLICATIONS\Tigard App.doc Rev 01/05/2012 2
- City of Tigard 4-71 Permit No.: — '1020/(0 —00 7
13125 SW Ha11 Blvd,Tigard,OR 97223 $k ..'s;4 rt
Phone: 503.718.2439 Fax: 503.598.1960 Date Received: /d+Aff
Inspection Line: 503.639.4175
TIGARD
Internet: www.tigard-or.gov o f 1 2 N I B By:
FIRE SPRINKLiR AFI II)AVI 1OR ALTERATIONS
:pi
OR ' ' NANT IMPROVEMENTS
(1 to 10 SPRINKLER HEADS WITHOUT PLANS)
Project Name: MIDDLEGATE RELOCATION Occupancy: LIGHT
Job Address: 6650 SW REDWOOD LANE #105 Type of Construction:
Suite:
Contractor: Wyatt Fire Protection Phone: 503-684-2928
Number of Proposed or Altered Heads: 1
Type: SSP Hazard: LIGHT Density: 0.10
I, Max Colley, Wyatt Fire Protection Oregon Construction Contractors Board No. 64077
certify the following is true and reasonably defines the scope of work for this project:
a) All work is limited to drops and armovers in a light-hazard occupancy.
b) Positions of sprinlder heads relative to architectural features such as soffits,beams,partitions,walls, etc.
complies with current adopted edition of NFPA 13.
c) The proposed work does not require hydraulic calculations.
d) Only one sprinkler head will be installed from one drop(exception: up to two heads from one drop may be
installed when each head is in a separate fire area).
e) The area covered per sprinlder head is limited to the spacing requirements of NFPA 13.
f) Tenant improvements in a new building shall be equipped with Quick Response heads (see 2002 NFPA 13,
Section 8.3.3.1 for exceptions).
g) The installation shall comply with the requirements of the current adopted edition of NPFA 13.
h) Piping shall not be concealed until hangers and bracing are inspected.
i) Final approval shall be subject to onsite tests and inspections.
In addition, I understand the following is required:
• Submit(3) copies of a sketch showing the area of work within the building's structure.
• Building fire protection system permit.
• A copy of this document with a co' of the sketch attached shall be available for all inspections.
Signature: ,
" Date: 10/12/2016
Print Name: Max Colley
I:\Building\Forms\FireSprinklerAffidavit 071514.docx
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