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Permit (10) iiii City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ni 44 Request for Permit Action T 1 GA 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: ❑ Owner ❑ Applicant ❑ Contractor t'.li•City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: 77.---........-77--........-' PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANL/VOID PERMIT APPLICATION. REFUNDRMIT 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#: PZ-- 7.13-e/7 -a)/..51C-- Site a)/S1C-- Site Address or Parcel#: 6, l 9c . Si.) 972 N_.. S j Project Name: 141 ei A/ TAr''r,9 /Z - -7 Subdivision Name: Lot#: EXPLANATION: 66z/77\16 //NJ Se_i/' 4`=' 6'IZ/ir2,,"(6-6ti()2, s;u ( 77.75s //) 0 g7-7 �V.Z 7J ,----:--K le 777i€'S • R ` / /i" aceta.. 'i1) Signature: 4i. Date: //fr/f 7 Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. zr 44 iS. 0/ 9,0/ - ,/ '' ft' /' .✓ - (U 7. 4 , I/ FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date f"'„6. Ae— "�. Refund Processed: Date r'� r �� Invoice Processed: Date By Permit Canceled: Date ^/ By Parcel Tag Added: Date B I:\Building\Forms\RegPermitAction_09 .14.doc y 1111111 4 TIGARD November 20, 2017 City of Tigard Oregon Cascade Plumbing&Heating 1728 22nd Street SE Salem, OR 97302 Re:Permit No. PLM2017-00155 Dear Applicant: The City of Tigard has processed a refund for overpayment of permit fees on the above referenced permit for the following: Site Address: 6996 SW Varns St. Project Name: Madrona Recovery Center Job No.: N/A Refund: ® Check #226775 in the amount of$67.26. ❑ Credit card "return"receipt in the amount of$ 0 Trust account"deposit"receipt in the amount of$ Notes: Change in the scope of work for the plumbing fixtures resulted in reduced permit fees. Refund 80% of the difference in permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Coordinator Enc. r:\Bading\Refunds3126nSa, ay N,tyif /Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov n City of Tigard r1cAxD 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: Oregon Cascade Plumbing& DATE: 11/9/2017 Heating 1728 22nd St SE Salem, OR 97302 REQUESTED BY: Diann Howse TRANSACTION INFORMATION: Receipt#: 410323 Case#: PLM2017-00155 Date: 5/1/2017 Address/Parcel: 6996 SW Varns St Pay Method: CreditCard Project Name: Madrona Recovery EXPLANATION: Change in scope of plumbing work resulted in reduced permit fees. Refund 80%of permit fees. > '; 5* ` * "' ,aux 'k'c,.a,a a' € # z �'s,'z ' dFT741,1;14105 -141 � olmo[ 3 . e $ * .i`* � i- :: ? CITY OF G It . 13125 SW Hall Blvd.TI,Tigard OR 97223 RECEIPT - 503.639.4171 T r<<�A f.h Project Name: Madrona Recovery Site Address: 6996 SW YARNS ST CASE NO. Receipt Number: 416580 - 04/06/2018 FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2017-00155 $-67.26 Total: $-67.26 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID Check CASHIER ID RECEIPT DATE RECEIPT AMT 226775 Payor: Oregon Cascade Plumbing&Heating DROWSE 04/06/2018 $-67.26 Total Payments: $-67.26 Balance Due: $67.26 Page 1 of 1 CITY OF TIGARD RECEIPT filill 1 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Madrona Recovery Site Address: 6996 SW VARNS ST Receipt Number: 410323 - 05/01/2017 I CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2017-00155 Sanitary Sewer 230-0000-43101 $62.54 PLM2017-00155 Water Service 230-0000-43101 PLM2017-00155 Clothes Washer $25.02 PLM2017-00155 230-0000-43101 $25.02 Fixture/Sewer Cap 230-0000-43101 PLM2017-00155 Floor Drain/Floor Sink/Hub 0.04$25.024 F-r *-- PLM2017-00155 230-0000-43101 $50 Primer 230-0000-43101 PLM2017-00155 12%State Surcharge-Plumbing $30.02 100-0000-24001 $30.02 Total: $280.20 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01899G Payor: Hans Radklev, Oregon Cascade Plumbing&Heating DHOWSE 05/01/2017 $280.20 Total Payments: $280.20 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD PLUMBING PERMIT .111 q COMMUNITY DEVELOPMENT Permit#: PLM2017-00155 f t GAR D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/12/2017 Parcel: 2S 101 DA01900 Jurisdiction: Tigard Site address: 6996 SW VARNS ST Project: Madrona Recovery Subdivision: VARNS ACRES Lot: 3 Project Description: Plumbing fixtures for TI Contractor: OREGON CASCADE PLUMBING&HEATING Owner: NELSON VIAL LLC 1728 22ND ST SE 7155 SW VARNES ST#120 SALEM, OR 97302 TIGARD, OR 97223 PHONE: 503-588-0355 PHONE: FAX: FEES Quantity Description Date Amount 35 If Sanitary Sewer 05/01/2017 $62.54 Specifics: 30 If Water Service 05/01/2017 $62.54 1 ea Clothes Washer 05/01/2017 $25.02 Type of Use: COM 1 ea Fixture/Sewer Cap 05/01/2017 $25.02 Class of Work: ALT 2 ea Floor Drain/Floor Sink/Hub 05/01/2017 $50.04 Type of Const: 2 ea Primer 05/01/2017 $25.02 Occupancy Grp: 1 12%State Surcharge- 05/01/2017 $30.02 Stories: Plumbing Total $280.20 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: 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_ CE'V ED ifuilding Fixtures q7 FOR OFFICE USE ONLY p� City of Tigard MAY 2017 Received C/ 7 / �,[� Permit No./O / ' //7"©©/33 Date/By: ••J 3 / III • 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review I Phone: 503.718.2439 Fax: 503.59�t / ry ry Other Permit j� R fh"h 1 OFA1TIGARD Date/By: 'lG/,r ��0 /9 TIGARD Inspection Line: 503.639.4175 BUILDING DIVISIO' DateReady/By: Jur s: H See Page 2 for Internet: www.tigard-or.gov BUILDING tl Notified/Method: Supplemental Information t , TYPE OF WORK I FEE* SCHEDULE ❑New construction ❑Demolition For special information use checklist. Description Qty. Ea. Total VAddition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 0 1-and 2-family dwelling VCommercial/industrial SFR(2)bath 437.78 SFR(3)bath 500.32 0 Accessory building 0 Multi-family Each additional bath/kitchen 25.02 0 Master builder ❑Other: Fire sprinkler(p//,.sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: /' 9% S' e� R� S I Catch basin or area drain 18.76 City/State/ZIP: / f°CA� � q1.2„).? Drywell,leach line,or trench drain/ 18.76 L/e� ` Footing drain(no.linear ft.:/W4) Page 2 Suite/bldg./apt.no.: Project name:�. we/h,4RI-to am/ C/,&.. Manufactured home utilities 50.03 Cross street/directions to job site: �'�IrY Manholes 18.76 Ir l®F S w f A� c r Rain drain connector , 18.76 0/f Q F Sc. ) 7) r /4ut"-� Sanitary sewer(no.linear ft.:5Y ) Page 2 f'" V Storm sewer(no.linear ft.:dL.� Page 2 Water service(no.linear ft.:_Le) Page 2 4),f c/ Subdivision: j / I Lot no.: Fixture or item: Tax map/parcel no.: / �► Backflow preventer 31.27 ® :: r Backwater valve 12.51 Clothes washer ✓ 25.02 s.0). --s L//,. 7r�C)/ /C:i&V1 A)r .../.... �i ��� Dishwasher 25.02 7IA)5: i/-14'13 13,61it✓2oe."1,+t c 7 4*(J Drinking fountain 25.02 /4--- t/o_ -hs' G(.4Sf/ 80'( Ejectors/sump 25.02 '"'T ❑ P1QPER ' O © I':. i� Expansion tank 12.51 a- Name: /4, �/. j��,��ixture/sewer cap I 25.02 ( ®fi- U " -'Floor drain/floor sink/hub .'/ 25.02 10 0 v Address: Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 APPLIC ❑ CONTACT PERS - Interceptor/grease trap 25.02 Business name:/� �// / u Medical gas(value:$.V)/l) Page 2 '/ o OG c !U'NI/3 /1.f Joh..., Primer 12.51 ,�,C L Contact name: / /.70,,44E,,,,,,,„, / r-- �,Q r- N� r 47A /ly�'�' 4L Roof drain(commercial) 12.51 Address: /ii 8 d.l k d $r7`! jt Sink/basin/lavatory 25.02 City/State/ZIP: S/(4/64- Ord- 3CASolar units(potable water) 62.54 Phone:(f 03 ) 5-Ap-03'5-j-- Fax::( ) f�(1y, Tub/shower/shower pan 12.51 E-mail: /, �„ �� p �� sr , ff al 25.02 Z f;Q)s11 d Gi7rer closet 25.02 NTRAer heater 37.52 Business name: L ?A i %I 4poa . erpiping/DWV 56.29 Address: Other: 25.02 City/State/ZIP: Subtotal Minimum permit fee: $72.50 zS� a Phone:( ) Fax:( ) /./-7 , Plumbing Lic.no.:,2/-�.03 Plan review (25%of permit fee) �� S'�--- CCB Lic.: / State surcharge(12%of permit fee) 3p.5",Z Authorized signature: PecIA:otc(d/e-ifrli TOTAL PERMIT FEE 5 s„I Print name: �CVti Date: .r/1j,� This permit application expires if a permit is not obtained within 180 days Safter it has been accepted as complete. �/. GI°c Foe 63�o �'P *Fee methodology set by Tri-County Building Industry Service Board. I:\Building\PermJits\PLMU-PermitApp.doc 10/01/09 f 440-4616T(10/02/COM/WEB) A Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty Fee(ea) Total Square Footage: Permit Fee: Footing drain-l s'100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer-1st 100' 62.54 7,201 and greater $327.54 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas Systems: Water Service-each additional 100' 37.52 Storm&Rain Drain-1st 100' 62.54 Valuation: Permit Fee: $1.00 to$5,000.00 Minimum fee$72.50 Storm& Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for Other Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to and including$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for which no fee is specifically indicated 90.00/hr each additional$100.00 or fraction thereof,to (minimum charge-1/2 hour) and including$25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for hours(minimum charge-2 hours) each additional$100.00 or fraction thereof,to Reinspection Fees 90.00/hr and including$50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for (minimum charge-1/2 hour) each additional$100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. Plan Review for Plumbing Installations Quantity by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate Baptistry/Font 0 Any new commercial building with water service 2"and greater,except systems designed and stamped by licensed Bath: -Tub/Shower -Jacuzzi/Whirlpool engineer. Car Wash: Each Stall 0 New exterior plumbing site utilities for any complex structure as defined in OAR918-780-0040. -Drive Thru Cuspidor/Water Aspirator 0 Medical gas and vacuum systems for health care facilities. Dishwasher: Commercial 0 Any multipurpose fire sprinkler system. Domestic 0 Any complex structure as defined in OAR918-780-0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" ometric or Riser Diagram 4„ 0 Isometric or riser diagram is required for new buildings -Car Wash Drain Garbage Domestic non-food that meet the qualifications above. Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower: -Gang -Stall Sink: -Lav/Bar non-food related -Bradley -Com/Serv/Util food related -Service *Note: If the fixture work under this permit results in an Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and Washer-Clothes fees assessed for the sewer increase must be paid before the Water Extractor Water Closet-Toilet plumbing permit can be issued. Urinal Other Fixtures: I:\Building\Permits\PLMF PermitApp.doc 08/04/2011 2 Plumbing Permit Application - City of Tigard • Page 2 - Supplemental Information Fee Schedule: Residential Fire Su• •ression S stems: Footing drain 1°100' 50.03 0 to 2,000 $121.90 Footing drain-each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer-1st 100' 62.54 7,201 and y eater $327.54 Sewer-each additional 100' 37.52 Water Service-1st 100' 62.54 Medical Gas S stems: Water Service-each additional 100' 37.52 Storm&Rain Drain-1st 100' 62.54 $1.00 to$5,000.00 Minimum fee$72.50 Storm&Rain Drain-each additional 100' 37.52 $5,001.00 to$10,000.00 $72.50 for the first$5,000.00 and$1.52 for each additional$100.00 or fraction thereof to and includin:$10,000.00. Inspection of existing plumbing or for $10,001.00 to$25,000.00 $148.50 for the first$10,000.00 and$1.54 for which no fee is specifically indicated 90.00/hr ■ each additional$100.00 or fraction thereof to minimum char:e-1/2 hour and includin.$25,000.00. Inspections outside of normal business - 90.00/hr - $25,001.00 to$50,000.00 $379.50 for the first$25,000.00 and$1.45 for hours minimum chane-2 hours each additional$100.00 or fraction thereof,to Reinspection Fees - 90.00/hr and includin:$50,000.00. Additional plan review for revisions - 90.00/hr - $50,001.00 and up $742.00 for the first$50,000.00 and$1.20 for (minimum ch• :e-1/2 hour each additional$100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping,adding or replacing fixtures? If"yes", please indicate work performed by fixture. Failure to accurately report fixtures could result in increased sewer fees*. Plan review is required for any of the following. B itis. /Font Please check all that apply. Bath Tub/Shower --- ❑ Any new commercial building with water service 2"and -Jacuzzi/Whirl•,,1 --_ greater,except systems designed and stamped by licensed Car Wash -Each Stall --- engineer. -Drive Thru --- 0 New exterior plumbing site utilities for any complex structure Cus.idor/Water As.irator --- as defined in OAR918-780-0040. Dishwasher -Commercial -- ❑ Medical gas and vacuum systems for health care facilities. -Domestic --- 0 Any multipurpose fire sprinkler system. Drinkin:Fountain -_ 0 Any complex structureas defined in OAR918-780-0040. E e Wash -� Floor Drain/sink -2" Submit 2 sets of plans with any of the above. -3" --- -4" Car Wash Drain Isometric or riser diagramis required for new buildings Garbage -Domestic-non-food --- Q g Disposal -Domestic-food related that meet the •ualifications above. -Commercial-food related --- -Industrial-food related --- Ice Mach./Refri..Drains -_ Oil S .arator Gas Station � Comments regarding fixture work: Rec.Vehicle Dum.Station Shower -Gang --- -Stall --- Sink/Lav -Non-food related -Bradley --_ -Commercial-food related -ServiceSw Washer n.Pool Filter *Note: If the fixture work under this permit results in an Washer-Clothes Water Extractor increase of sewer EDUs,a sewer permit will be issued and Water Closet-Toilet w-- fees assessed for the sewer increase must be paid before the Urinal plumbing permit can be issued. Other Fixtures: http://www.tigard-or.gov/document centerBuilding/PLMF PermitApp.dc� City of Tigard 13125 SW Hall Blvd. Tigard, OR 97223 Tel: 503.718.2439 Location: Inspection Date: 6996 SW VARNS ST, TIGARD, OR, 97223 Record Type: Record ID: Commercial - Plumbing PLM2017-00155 Inspection Type: Inspector: 399 Plumbing final Don Sylvester Result: PASS - NoCofO Comments: 1 . Plumbing final for new laundry room - approved Violation Summary: Inspector Contractor