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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT., ECEiVcri Request for Permit Action q � TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-thou8 2017 OP) - lRJA ?D BUILDING Dfvfq 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 ❑ City Staff Check(✓)one REFUND OR Name: / 1{ nI,V"^ INVOICE TO: (Business or Individual) t ' ��ati V7 S(Wri ita-m46-5 Mailing Address: t (0 10 S cos -ro- fiat) City/State/Zip: 17(.. Q //��yy�' Phone No.: C��j -/06 C/� !� PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 6a' 5'0 3 -5 7c;20 ❑ 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#: H GJi-° /6 —6056g Seag,,20/6 4041'-1 Site Address or Parcel#: b D?i2. C,2) (-71 ¶ c' -t OP- .97-2 -z-2 Subdivision Name: �� rJ ��l Lot#: EXPLANATION: , 4 . �1 a1 �i. ?�° di _ / = 16raxv7-0co554'`at t2-Dot7-0605-e) INK Signature: Date: 2--12 I f7 Print Name: yA , - r// Refund Policy 11 S W esi-I a-K.i- 0 1 + Co 1. The city's Community Developmeircbirector,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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 s /7 A Route to Records: Date 3 Z'/ /7 B -- Refund Processed: Date '/207 By y/ Invoice Processed: _ Date By Permit Canceled: Date i3c0//7 By, '" Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_09 314.doc Iq TIGARD City of Tigard March 15,2017 Westland Custom Homes Attn: Jim Standring 12670 SW 68th Ave., Suite 400 Tigard, OR 97223 Re: Permit No. MST2016-00508 &SWR2016-00424 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 15022 SW Corbin St. Project Name: Corbin Estates,Lot 10 Job No.: N/A Refund Method: ® Check#224152 in the amount of$35,964.77. ❑ Credit card "return" receipt in the amount of$ . 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): Per applicant's request as house plans were changed and submitted under a new permit. Refund 100% of permit fees and SDC fees. If you have any questions please contact me at 503.718.2430. Sincerely, /e ku'zft Dianna Howse Building Division Services Supervisor Enc. 13125 SW I Iall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov 11 IR C 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 PermitAction 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: Westland Custom Homes DATE: 3/10/2017 Attn: Jim Stanching 12670 SW 68th Ave, Ste. 400 REQUESTED BY: Dianna Howse Tigard, OR 97223 DA TRANSACTION INFORMATION: Receipt#: 408301/408302 Case#: MST2016-00508/SWR2016-00424 Date: 1/10/2017 Address/Parcel: 15022 SW Corbin St. Pay Method: Credit Card Project Name: Corbin Estates,Lot 10 EXPLANATION: Per applications request as they changed house plans.Refund 100%of permit fees. ,+ � ,.,x h �-3' $„ mac c x ,y, Faw e ® , i ® f 1 0, it . iv t "s`.:`s- '['- 3s- _ ° "yr p i '�- n� r a ;IN .. :. t E',:4%®"6t a e- •d „r;, x #. E e:1-0RON, 0E-000 Building Permit 230-0000-43104 $2,365.92 Mechanical Permit 230-0000-43102 324.31 Electrical Permit 220-0000-43103 480.98 Plumbing Permit 230-0000-43101 550.36 12%State Surcharge 100-0000-24001 446.59 Metro Construction Excise Tax 230-0000-24010 526.01 Tig-Tual School CET–Residential 230-0000-24102 4,213.20 Erosion Control w/Development 100-0000-43134 461.40 Tigard Trans SDC Improvement–SF 415-0000-43300 5,488.00 Tigard Trans SDC Reimbursement–SF 415-0000-43301 317.00 Washington County Trans Dev Tax–SF 405-0000-43320 8,278.00 Parks SDC Improvement 425-0000-43300 4,356.00 Parks SDC Reimbursement 425-0000-43301 1,207.00 Parks SDC Neighborhood 425-0000-43300 1,615.00 Sewer Connection Fee 500-0000-25500 5,300.00 Sewer Inspection Fee 230-0000-43118 35.00 TOTAL REFUND: $35,964.77 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,500 Department Manager ���'Lr' '✓G-GL/�'� If under$50,000 City Manager If over$50,000 Local Contract Review Board A1/4 - ,FOR TIDEMARK SYSTEM ADMINISTRATION;US)! ONLY Case Refund Processed: Date: 3/Z y//7 By: , — I:\Building\Refunds\RefundRequest.doc x 12/21/2016 CITY OF TIGARD SEWER CONNECTION PERMIT IN Ir 'f COMMUNITY DEVELOPMENT Permit#: SWR2016-00424 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 01/10/2017 I 9 Parcel: 2S112CB19300 Jurisdiction: Tigard Site address: 15022 SW CORBIN ST Project: Corbin Estates, Lot 10 Subdivision: CORBIN ESTATES Lot: 10 Project Description: Sewer connection for new SF Contractor: Owner: ANDERSON HOMES&CONSULTING LLC 12600 SW 72ND AVE, STE 200 TIGARD, OR 97223 PHONE: PHONE: FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 01/10/2017 $5,300.00 Type of Use: SF Sewer Inspection-Residential 01/10/2017 $35.00 Class of Work: NEW Install Type: Line Tap and Building Sewer Fixture Units: Number of Dwelling Units: 1 Total $5,335.00 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. T rules -re 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.y calling 503.2 '.198 .r 1.800.332.2344. Iss ed By: / , / ' Permittee Signature: x. Call 503.639.4175 by 7:00 a.m.for the next available insp t n da . 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 inspe ion.