Permit (48) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT VOID w
Request for Permit Action 3/73/i 7
Ti G A R D 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: 0 Owner ❑ Applicant E] Contractor WAity Staff
Check V)one
REFUND OR Name:
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city/state/zip: (/6}r1JCQ'St Ve7z, `09 99d�(6
Phone No.: /9--7j�.' /kii/6j--'Z9— •
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).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT (do not ca
Permit#: /7S7-e20/ly 017.5-y 7 J" al2 /4, f 9-5 7
Site Address or Parcel#: /73fe2 fed .57j`rfzs 3 772ff/L 5'%
Subdivision Name: teen._ `u_ E- ..tro )wities'T-Lot#: i/..�
EXPLANATION: 7,-‘5 vf'f/T-A✓EZC/ ,Z4-ALS tfA/-6 t.JZ
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 .23 /f B G--
Refund Processed: Date rAirio By Invoice Processed: Date By
Permit Canceled: Date ' By Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_o42314. oc
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111111
TIGARD
City of Tigard
May 2, 2017
Polygon WLH,LLC
Attn: Angela Grajewski
109 East 13th St
Vancouver,WA 98660
Re: Permit No. MST2016- 47/SWR2016-00457
Dear Applicant
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 17382 SW Shadow Trail St
Project Name: River Terrace Northwest,Lot 115
Job No.: N/A
Refund Method: ® Check#224417 in the amount of$38,542.50.
❑ Credit card"return"receipt in the amount of$ .
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): Pet applicant's request as house plans were changed. Refund 100% of
permit fees and 80% of plan review fees. Plans resubmitted under MST2017-00106 and
SWR2017-00095.
If you have any questions please contact me at 503.718.2430.
Sincerely,
i'COS02,101-<__,
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
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: Polygon WLH,LLC DATE: 4/17/2017
Attn: Angela Grajewski
109 East 13th St. REQUESTED BY: Dianna Howse
Vancouver,WA 98660
TRANSACTION INFORMATION:
Receipt#: 408425 &408426 Case #: MST2016-00547/SWR2016-00457
Date: 1/23/2017 Address/Parcel: 17382 SW Shadow Trail St
Pay Method: Check Project Name: River Terrace Northwest,Lot 115
EXPLANATION: Per applications request as they changed house plans. Refund 100% of permit fees&
80%of plan review fees. Resubmitted under MST2017-00106&SWR2017-00095.
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Building Permit 230-0000-43104 / $1,963.70 V
Mechanical Permit 230-0000-43102 / 324.42 ✓
Electrical Permit 220-0000-43103 413.14 .V
Plumbing Permit 230-0000-43101 ✓ 500.32 ✓
12%State Surcharge 100-0000-24001 - 384.19 V
Metro Construction Excise Tax 230-0000-24010 ✓ 417.49 ✓
Beaverton School CET—Residential 230-0000-24101 J. 3,538.71 ✓
Erosion Control w/Development 100-0000-43134 ✓ 311.40 ✓
Tigard Trans SDC Improvement—SF 415-0000-43300 / 5,488.00 ✓
Tigard Trans SDC Reimbursement—SF 415-0000-43301 / 317.00 ✓
Tigard Trans SDC River Terrace—SF 415-0000-43302 ✓ 2,684.00 ✓
Parks SDC Improvement 425-0000-43300 / 4,356.00 ✓
Parks SDC Reimbursement 425-0000-43301 ✓ 1,207.00 ✓
Parks SDC River Terrace 425-0000-43302 ./ 2,003.00 ✓
Sewer Connection Fee 500-0000-25500 ,/ 5,300.00 V
Sewer Inspection Fee 230-0000-43118 / 35.00 ."--
Building Plan Review 230-0000-43106 / 1,021.13 ✓
Washington Co Trans Dev Tax—SF Detached 405-0000-43320 ✓ 8,278.00
TOTAL REFUND: $38,542.50
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager OV
J
If under$50,000 City Manager Or /
If over$50,000 Local Contract Review Board
Mg ITAVENIARX SYSTRM APM ISTRA'TION USE ONLY : ':(�
Case Refund Processed: Date: G2/'-j/cr By: /'
I:\Building\Refunds\RefundRequest.doc x 12/21/2016
CITY OF TIGARD RECEIPT
6 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: River Terrace Northwest, Lot 115
Site Address: 17382 SW SHADOW TRAIL ST
Receipt Number: 415785 - 02/23/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2016-00457 $-5,335.00
Total: $-5,335.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 224417 DHOWSE 02/23/2018 $-5,335.00
Payor: Polygon WLH, LLC
Total Payments: $-5,335.00
Balance Due: $5,335.00
Page 1 of 1
CITY OF TIGARD RECEIPT
- V
0 _ 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
o2/6 (v' '—
Receipt Number: 408426 - 01/23/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2016-00457 Sewer Connection Fee 500-0000-25500 ✓ $5,300.00 �—
SWR2016-00457 Sewer Inspection-Residential 230-0000-43118 $35.00 (—
Total: $5,335.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 71333 DHOWSE 01/23/2017 $5,335.00
Payor: Polygon WLH, LLC
Total Payments: $5,335.00
Balance Due: $0.00
Page 1 of 1
IL CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2016-00457
Date Issued: 01/23/2017
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 parcel: 2S 23/201 1500
Jurisdiction: Tigard
Site address: 17382 SW SHADOW TRAIL ST
Project: River Terrace Northwest,Lot 115 Subdivision: RIVER TERRACE NORTHWEST Lot: 115
Project Description: Sewer connection for new SF
Contractor: Owner: ADLV LAND HOLDINGS LLC
BY FORSUM, MICHAEL
7600 E DOUBLETREE RANCH RD STE 1
SCOTTSDALE,AZ 85258
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 01/23/2017 $5,300.00
Sewer Inspection-Residential 01/23/2017 $35.00
Type of Use: SF
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. 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 50 or 1.800.332.2344.
Issued By: • i P )7 -- Permittee Signature: 61 45/2L.
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.