Permit (43) ,RECEIVED
City of Tigard • comMUNITY DEVELOPMND
NT EPAIU1111 i.
-':. Request for Permit Action
IN
CITY OF TIGARD
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13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • ,".1.; ,t Ste c,to 44,,, ,
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.........................................................,
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 Tigard.BuildingPerrnits@tigard-or.gov
FROM: 0 Owner 0 Applicant EA Contractor [3 City Staff
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REFUND OR Name: ,
INVOICE TO: (suNines or Individual) .. / , ,. , -
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Phone No.: (:-1-73(:>5.,) - 9):\t(s
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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CANCEL/VOID PERMIT APPLICATION.
0 0 REFUND PERMIT FEES (attach copy of original receipt and provide explanation helm).
INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
1:3 REMOVE/RITI,ACE CON'IRACTOR ON PERMIT(do not cancel permit).
Permit#:
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Site Address or Parcel#: \ A --C\
Project Name:
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Subdivision Name: \\_/\1\-\\AC r
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I. The city's Community 1)evelopment Director,Building OfAcial or City Engineer may authorize the refund or
• 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 7v7.so ,..... 3---,;p-.. e,-7) 7 / ....Ce
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FOR OFFICE USE(.)N La"
Route to Sys Admin: Date ifs/ By Pr" Route to Records: Date 3 /73 /, 3v i
Refund Processed: Date , A, B' •gAir nvoice Processed: Date By
Permit Canceled: Date if /2' By , . Parcel Tai Added: Date By
t:\Buiaing\Forms\Re,..1PenniiAcrion_09231 .doc,
.� N
TIGARD
September 21,2017 City of Tigard
DR Horton, Inc.
Attn: Emerald Weeks
4380 SW Macadam Ave.,Ste 100
Portland, OR 97239
Re: Permit No. PLM2016-00627
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15429 SW Applewood Ln
Project Name: Heritage Crossing,Lot 42
Job No.: N/A
Refund Method: ® Check#226146 in the amount of$64.96.
0 Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account "deposit"receipt in the amount of$ .
Comment(s): Per applicant's request as work was not completed. Refund 80% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
<01;j;l--/-070—ye____
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
3 ty of Tigard
TIGARD AccelaCiRefund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Bequest 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: DR Horton,Inc. DATE:
Attn: Emerald Weeks 9/18/2017
4380 SW Macadam Ave., Ste 100 REQUESTED BY: Dianna Howse
Portland, OR 97239
TRANSACTION INFORMATION:
Receipt#: 409611 Case#: PLM2016-00627
Date: 3/24/2017 Address/Parcel: 15429 SW Applewood Ln
Pay Method: CreditCard Project Name: Heritage Crossing,Lot 42
EXPLANATION: Per applicant's request as work was not completed. Refund 80%of permit fees.
5 ..^,r s` ter* M,S k .e - F' ', J €
<. e.�4
�v4 4Mi C @ te( S1EPlumbing Permit ar
12%State Surcharge 230-0000-43101 $58.00
100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES/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
Case Refund Processed: ��-
Date: ��" ��, B .�.--
\Building\Refunds\RefundRequest.doc x 09/01/2010
Ih �d
lCITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Heritage Crossing, Lot 42
Site Address: 15429 SW APPLEWOOD LN
3
I Receipt Number: 416292 - 03/23/2018
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
PLM2016-00627
$-64.96
Total: $-64.96
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226146 DHOWSE 03/23/2018
Payor: D R Horton,Inc. $-64.96
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD
ilk 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
TIC;,11?I)
Project Name: Heritage Crossing, Lot 42
Site Address: 15429 SW APPLEWOOD LN
IReceipt Number: 409611 - 03/24/2017 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
PLM2016-00627 Backflow Preventer
PLM2016-00627 12%State Surcharge-Plumbing 200-0000-24101 $31.27
PLM2016-00627 100-0000-24001 $8.70
Minimum Fee Adjustment-Plumbing 230-0000-43101
$41.23
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE
ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 083231
Payor: dr horton PUBLICUSERO 03/24/2017 $81.20
Total Payments: $81.20
Balance Due: $0.00
I
Page 1 of 1
` a
CITY OF TIGARD PLUMBING PERMIT
' COMMUNITY DEVELOPMENT Permit#: PLM2016-00627
TF t1RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/27/2017
Parcel: 2S111 DA22300
Jurisdiction: Tigard
Site address: 15429 SW APPLEWOOD LN
Project: Heritage Crossing, Lot 42 Subdivision: HERITAGE CROSSING Lot: 42
Project Description: Backflow preventer for irrigation.
Contractor: TRADEMARK LANDSCAPES INC Owner: DR HORTON INC.
PO BOX 2410 4380 SW MACADAM AVE STE 100
OREGON CITY, OR 97006 PORTLAND, OR 97239
PHONE: 503-631-3893 PHONE: 503-222-4151
FAX: 503-631-4737
FEES
Quantity Description Date Amount
1 ea Backflow Preventer 03/24/2017 $31.27
Specifics: 1 12%State Surcharge- 03/24/2017 $8.70
Plumbing
Type of Use: SF 41 ea Minimum Fee Adjustment- 03/24/2017 $41.23
Class of Work: OTR Plumbing
Type of Const:
Occupancy Grp:
Stories:
Total $81.20
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 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
,,a,&//6(74-74
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.
Plumbing Permit Application
Building Fixtures NECEIVED
I0u 00th ,: 1 .1 MI
at)*of Tigard n R ;,�
• 13125 SW'Hall Blvd,Tigard.OR 97 )V 2 016 Date`B - �.� � Penni'
11111 • Phone: 503 718 2439 Fax. 50" Ptah Re�xa t o. /
1 i,.n ii a Inspection Line: 503.639.4175 l�1I Y Ti—ARD
DR
Other Permit`o.
Internet. w�\\tugazd-or.gov BUILDING NISI, DateReadyBy 7,�
ISI Noii6ed'bteitiod: i t1e1s See Page 2 for
TYPE OF WORK Sup ental Information
(a NewconstructionFE£` SCHEDULE
0 Demolition For , eial in omatims ase checklist
❑Addition/alteration/replacement 0 Other Descri.non MEa Total
New I-2-family dweBin•s(includes 100 ft.for each utility connection)
CATEGORY OF CONSTRUCTION SFR(I)bath
el 31.70
1-and 2-family dwelling ❑Commercialtindustnal
SFR SFR 12)bath
❑Accessory building437 78
0 Multi-family
(3)bath
500.32
Each additional bath1iitchen 5 02
❑Master builder 0 Other
JOB SITE INFORMATION AND LOCATION Fire sprinkler t so:8_1 103
3
Site utilities:
lob site address: ,
CSW ,G / ,`J .4..L Catch basin or area drain 18 76
111111111111
Drpwell,leach line,or trench drain 18.76
Suite/bldg/apt.no.. Project name Footing drain(no.linear ft.:_) I
City/State/ZIP: Tl:ard, OR 97223
Mil
n Manufactured home utilities
Cross street/directions to job site: SO.U3
Manholes
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_,-_j Page2
Storm sewer(no.linear ft.: _i Page 2
Water service(no linear ft.. ) Page 2
Subdivision: Lot no.:
MU
Tax map/parcel no.:
a.
Backflow preventer 1
DESCRIPTION OF WORK Backwater valve ��
New SFR Clothes washer 25 02
Dishwasher 23.02
Drinking fountain 25.02
Ejectors'sump 25 02 r
• PROPERTY OWNER
0 TENANT Expansion tank ®ININI
Name: DR Horton Inc. fixture/sewer cap 2sot
Address.4380 SW Macadam Ave Suite 100 Floor drain/floor stnklhub 25 02
Cit)/State/ZIP: Portland,OR 97239 Garbage disposal 25.02
ME
Phone:(503)222-4151 Fax,( Hose e 25.02
) Ice maker
0 APPLICANT 12 51
C'OXTACT PERSON Interceptor/grease trap 25 02P
Business name: DR Horton Inc. Medical gas(value.S
Contact name ) 2
Emerald Weeks P`imer 12.51
Address 4380 SW Macadam Ave Suite 100 Roof drain(commercial) 2
City/State/ZIP Portland, OR 97239 Sin nilavaton 25 02
Solar units(potable water) 11331
Phone:(503 )222-4151 x1107 Fax
1 1'ub'sltower'showerpnn 11911IIIIIIIIII�
E-mail: esweeks@drhorton.com urinal
25 02
CONTRACTOR Water closet 25.02
Business nameTrademark Landsca•es Inc Fater heater ®_
Address: i, • :e 1
Water piping'D\�'V �_
Cit}State/ZIPef' 25 0.
are:on ClCi , OR 97045
r ".r! Subtotal
.!.a . Minimum permit fee: 572.30
Phone:(503) 631-3893 '
" Plumbin�Lia.no:3-,3r Plan ret ig r25%of permit fee)
CCB Lic.: l3 -
Authorized signature: y � 1 State surcharge(12of permit fee) MI
Print name: � L j/�S TOTAL PERMIT FEE
Date 2O 16 I This permit application expires ira permit is not obtained within WO days
ahet it hes been accepted as compkte.
Fee methodology set b.,Tri-County Building Industry Service Board.
r BuddingPemiiisPl\tr:•PermitApp.do. 10 01 09
449-19i61139 92 COM WEBi