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Permit (28) ,,.- CITY OF TIGARD SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT V4 IN Permit#: SWR2017-00144 T[43 .R.D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 06/12/2017 Parcel: 2S 101 DA01900 Site address: 7000 SW VARNS ST Jurisdiction: Tigard Project: Madrona Recovery Project Description: 1.69 EDU increase. 4/6/2018: REPRINT permit to correct EDU'countn visio : VARNS ACRES Lot: 3 Contractor: Owner: NELSON VIAL LLC 7155 SW VARNES ST#120 TIGARD, OR 97223 PHONE: PHONE: FAX: Description Date Specifics: Amount Sewer Connection Fee 06/12/2017 Type of Use: COM $8,957.00 Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: 1.69 Total $8,957.00 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 503.23 987 or 1.800.332.2344. Issued By: _ Permittee Signature: ry/l1---/ ;02./,C Call 503.639.4175 by 7:00 a.m.for the next available inspection date. (/ n� 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. Accumulative Sewer Tally �>;�is \ i Tenant Name: Madrona Recove T t G A RD Site Address: 7000 SW Varns St SWR# 2017-00144 REVISED Parcel#: 2S1011: PLM# 2017-00154 Fixture Value Previous Previous Credits Capped Fixture Fixture New ew # value count ca, ed#s value count added# added value total#s total values Ba tise /Font 4 0 0 0 Bath: -Tub/Shower 4 0 0 0 0 0 - acuzzi/Whirl,ool 4 0 0 0 0 0 Car Wash: -Each Stall 6 0 0 0 0 0 -Drive throu:h 16 0 0 0 0 0 Cus Sidor/Water As sirator 1 0 0 0 0 0 Dishwasher: -Commercial 4 0 0 0 0 0 -Domestic 2 0 0 0 0 0 Drinkin_Fountain 1 10 10 0 0 1 1 E e Wash 1 1 1 0 0 0 Floor Drain/Sink: -2 inch 2 0 0 0 1 -3 inch 5 0 2 6 12 5 10 -4 inch 6 0 0 0 0 0 - 0 0 0 0 Car Wash 6 0 Garba�eDis.osal: 0 0 0 0 ' -Domestic to 3/4 HP 16 - 0 0 0 -Commercial to 5 HP 32 0 0 0 0 0 -Industrial over 5 HP 42 0 0 0 0 0 Ice Machine/Refri_erator Drain 1 0 0 0 0 0 Livin_Unit 16 0 0 0 0 0 Oil Se, Gas Station 6 0 0 0 0 0 Rec.Vehicle Dum. station 16 0 0 0 0 0 Shower: -Gan! ser head 1 0 0 0 0 0 0 0 -Stall 2 Sink: 0 0 3 6 3 6 -Lav/Bar-Non-Food Related 2 - 0 1 2 3 6 -Bradle 5 2 4 0 0 0 -Com/Sery/Util-Food Related 3 0 0 0 0 0 Swimmin_Pool Filter 1 0 0 0 0 0 Washer-Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet-Toilet 6 0 0 0 0 2 12 2 12 Urinal 6 0 1 6 0 Previous EDU Count_ -1 -6 0 Capped EDU Credit_ 0 TOTALS 0 0 0 3 10 15 37 Current Fixture Value 27 divided b 16= 12 27 Y 1.688 Current EDU 1 EDU= Previous Fixture Value 0 divided by16= $5,300.00 0.000 Previous EDU Change 27 divided by 16= 1.688 over (under) $ 8,957.00 Enter EDU Change Here 1.690 * *Round EDUs to the nearest 1/100th: a count endin>in.005 shall be rounded us to.01,and a count endin. in.014 or less shall be rounded down to.01. Notes: ' Authorized Name/Signature: Dianna Howse Date: 11/9/2017 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I:\Building\Sewer Tally\SewerTallySheet_5300_070116.xlsx .� Accumulative Sewer Tall yk/C'�it/ / a Tenant Name: Madrona Recovery L� TIGARD Site Address: 7000 SW Varns St SWR# 2017-00144 Parcel#: 2S 101 DA01900 PLM# 2017-00154 Fixture Value Previous Previous Credits Capped Fixture Fixture ew New # value count capped#s value count added# added value ttotal#s total values Baptisery/Font 4 0 Bath: -Tub/Shower 0 0 1 0 4 0 0 -Jacuzzi/Whirlpool 4 0 1 0 0 0 0 Car Wash: -Each Stall i 6 1 0 0 0 0 -Drive through 16 1 0 0 0 0 Cuspidor/Water Aspirator 1 0 0 0 0 0 Dishwasher: -Commercial 4 0 0 0 0 0 -Domestic 2 0 Q 0 0 1 il Drinking Fountain 1 , MN-a© 0 , 0 1 Eye Wash 1 111111111 1 0 0 0 Floor Drain/Sink: -2 inch 2 0 ' 0 0 3 inch 5 1 0 6 12 6 12 -4 inch 6 0rill 0 MEM 1 0 0 -Car Wash 6 I 0 0 0 0 0 GarbageI I 0 I 0 Disposal: 0 0 -Domestic(to 3/4 HP) 16 0 i 0 0 0 0 -Commercial(to 5 HP) 32 0 0 0 0 0 Industrial(over 5 HP) 42 0 , 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 i 0 Living Unit 16 0 0 0 0 0 Oil Sep(Gas Station) 6 0 0 0 0 0 Rec.Vehicle Dump station 16 0 0 0 0 0 Shower: -Gang(per head) 1 0 0 0 Stall 2 0 0 0 0 0 ill 0 3 6 3 6 Sink: -Lay/Bar-Non-Food Related 2 1 0 -Bradley 5 111 0 3 6 3 6 0 0 0 -Com/Sery/Util-Food Related 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer-Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet-Toilet 6 0 0 Urinal 6 0 0 2 12 2 I 12 0 0 0 Previous EDU Count 0 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 0 15 37 15 Current Fixture Value 37 divided b 16 37 Y = 2.313 Current EDU 1 EDU= Previous Fixture Value 0 divided b 16= $5,300.00 Y 0.000 Previous EDU Change 37 divided by 16= 2.313 over (under) $ 12,243.00 Enter EDU Change Here 2.310 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: Authorized Name/Signature: Dianna Howse Date: 5/1/2017 Building Division ote: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I I:\Building\Sewer Tally\SewerTallySheet_5300_070116.xlsx IN City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action 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 TigardBuildingPerrnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ ContractorCity Staff Check(V)one REFUND OR Name: INVOICE TO: (Business or Individual) r„' Mailing Address: .., ~ City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): ❑ CANCEL/VOID PERMIT APPLICATION. 4.7 FT:N RMIT FEES (attach copy of original receipt and provide explanation below). ill ., INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). Permit#: —Sidi(' e -O/ 7 — O 0 / ' V Site Address or Parcel#: 7 0 0 o ,s-C i 1,472"if..c. S%__ Project Name: /7,9-1j, ,'v ___E-:ee t//,.72 ,,. Subdivision Name: Lot#: EXPLANATION: em9/\06-- ' //\,/ S C ' c' - 'till/21e_ ei L C f-t 6/A.16. rE-72-,7/ j �G.- S. to G.- i 67O. //V /e C--- —A �/ ' ` Signature: 1 'mss T L P'.x--L - Date: /// Print Name: "Jeve /� 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. FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date Refund Processed: Date r74 0 �B64--BY /f Invoice Processed: Date By Permit Canceled: Date By -arcel Tag Added: Date I:\Building\Forms\RegPermitAction_092314,doc By n TIGARD City of Tigard November 20,2017 Madrona Recovery Center 7000 SW Varns St Tigard, OR 97223 Re: Permit No. SWR2017-00144 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: 7000 SW Varns St. Project Name: Madrona Recovery Center Job No.: N/A Refund: ® Check#226763 in the amount of$3,286.00. ❑ Credit card "return"receipt in the amount of$ ❑ Trust account"deposit"receipt in the amount of$ Notes: Change in the scope of work for the plumbing fixtures resulted in reduced sewer system development charges. If you have any questions please contact me at 503.718.2430. Sincerely, r Dianna Howse Building Division Services Coordinator Enc. \Building\Refuncls3AWi .kal ? 'Egon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov - Community Development TIcAaD WILL CALL/PICK UP Fill out this form completely and attach it securely to the document(s). Bring it to the WILL CALL/PICK UP area at the Permit Center Counter and file alphabetically by last name of individual or company name. TO: f7/A/ COMPANY NAME: /74L'erNt/- i2 p// y DOCUMENT NAME: t /°C, FROM: ., i.�- v DEPARTMENT: C.6 DATE TO Will. CALL: ///2///7 FEES DUE: ATTACH FEE INFORMATION(ACCOUNTS,PERMITS,COPIES,ETC.) Document will be returned to the originator if not picked up within 5 business days of the'DATE TO WILL CALL". RECEIVED BY: I MUST BE SIGNED ' 'TH PERSON LISTED ABOVE RECEIVED DATE: DATE RETURNED TO ORIGINATOR: \Budding\Fovn4\Rteshp-wisciadoc N 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 forPermit 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: Madrona Recovery Center DATE: 11/9/2017 7000 SW yarns St Tigard, OR 97223 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 411132 Case#: SWR2017-00144 Date: 6/12/2017 Address/Parcel: 7000 SW Varns St Pay Method: Check Project Name: Madrona Recovery EXPLANATION: Change in scope of plumbing work resulted in reduced sewer SDC fees. Refund 100% of the difference. ar �• S' r � ��� 3a+t � : z��s..�Z � � 8 ,�',� �',�",.;,s'��� ;�f,� 'R,rx w .as.,���` NIf �;. ej 4.0e l a Krir # $'3��� -SV 1 `i . a & �� ��w�� "��1 r Sewer Connection Fee 500-0000-25500 $3,286.00 TOTAL REFUND: $3,286.00 APPROVALS: SIG /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 "F©R'Ti EMARK SYsTE G1 ADWINIS ' 'ri N ., NLY $ Case Refund Processed: Date: Or ' By. I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD iill RECEIPT it13125 SW Hall Blvd.,Tigard OR 97223 T f CI A T1 D 503.639.4171 Project Name: Madrona Recovery Site Address: 7000 SW VARNS ST /ZEr-C-1.Vb I Receipt Number: 416585 - 04/06/2018 I CASE NO. SWR2017-00144 FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID $-3,286.00 Total: $-3,286.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID Check CASHIER ID RECEIPT DATE RECEIPT AMT 226763 DHOWSE Payor: Madrona Recovery Center 04/06/2018 $-3,286.00 Total Payments: $-3,286.00 Balance Due: $3,286.00 Page 1 of 1 CITY OF TIGARD RECEIPT 1 • 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIG tRD Project Name: Madrona Recovery Site Address: 7000 SW VARNS ST I Receipt Number: 411132 - 06/12/2017 I CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID SWR2017-00144 Sewer Connection Fee 500-0000-25500 $12,243.00 Total: $12,243.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1086 BTAGGART 06/12/2017 Payor: Madrona Recovery Center Inc. $12,243.00 Total Payments: $12,243.00 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD - Building Division 11/9/2017 Project Name: Madrona Recovery Permit#�: ��� Address # 00144 7000 SVarns A Bldg' Paid _ Adjusted Refund Fees Due Notes $ 12,243.00 $ 8,957.00 $ 3,286.00 Credit for capped fixtures:floor drain,sink,urinal PLM2017-00154 7000 SW Varns A $ 903.66 $ 987.73 $ 84.07 Fees for(3) SWR2017-00145 6996 SW Varns B capped fixtures not on original permit $ 1,325.00 $ 2,014.00 $ 689.00 Remove new floor drains&credit for capped urinal PLM2017-00155 6996 SW Varns B $ 280.20 $ 212.94 $ 67.26 Remove floor drains&capped urinal from permit Total: $ 3,353.26 $ 773.07 Refund: $ 3,353.26 Fees Due: $ 773.07 Net Refund: $ 2,580.19 CITY OF TIGARD SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT Permit#: SWR2017-00144 and OR 97223 503.718.2439 13125 SW Hall Blvd.,Ti Date Issued: 06/12/2017 T[tok�.iLs 9 Parcel: 2S 101 DA01900 Jurisdiction: Tigard Site address: 7000 SW VARNS ST Project: Madrona Recovery Subdivision: VARNS ACRES Lot: 3 Project Description: 2.31 EDU increase. Contractor: Owner: NELSON VIAL LLC 7155 SW VARNES ST#120 TIGARD, OR 97223 PHONE: PHONE: FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 06/12/2017 $12,243.00 Type of Use: COM Class of Work: ALT Install Type: Building Sewer Fixture Units: Number of Dwelling Units: 2.31 Total $12,243.00 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 503.232.1987 or 1.800.332.2344. Issued By: /...."04,..r.4, Permittee Signature: cAe a1f 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. C Tenant Name: Madrona RecoverAyccumulative Sewer Tally SWR# 2017-00144 T►GARD Site Address: 7000 SW Varns St PLM# 2017-00154 Parcel#: 2S101 DA01900 Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value count capped#s value count added# added value total#s total values Baptisery/Font 4 0 0 0 0 0 Bath: -Tub/Shower 4 0 0 0 0 0 -Jacuzzi/Whirlpool 4 0 0 0 0 0 Car Wash: -Each Stall 6 0 0 0 0 0 -Drive through 16 0 0 0 0 0 Cuspidor/Water Aspirator 1 0 0 0 0 0 _ Dishwasher: -Commercial 4 0 0 0 0 0 -Domestic 2 0 0 0 0 0 Drinking Fountain 1 0 0 1 1 1 1 Eye Wash 1 0 0 0 0 0 Floor Drain/Sink: -2 inch , 2 0 0 6 12 6 12 -3inch 5 0 0 0 0 0 -4 inch 6 0 0 0 0 0 -Car Wash 6 0 0 0 0 0 Garbage Disposal: -Domestic(to 3/4 HP) 16 0 0 0 0 0 -Commercial(to 5 HP) 32 0 0 0 0 0 -Industrial(over 5 HP) 42 0 0 0 0 0 Ice Machine/Refrigerator Drain 1 0 0 0 0 0 Living Unit 16 0 0 0 0 0 Oil Sep(Gas Station) 6 0 0 0 0 0 Rec.Vehicle Dump station 16 0 0 0 0 0 Shower: -Gang(per head) 1 0 0 0 0 0 -Stall 2 0 0 3 6 3 6 Sink: -Lay/Bar-Non-Food Related 2 0 0 3 6 3 6 -Bradley 5 0 0 0 0 0 -Com/Serv/Util-Food Related 3 0 0 0 0 0 Swimming Pool Filter 1 0 0 0 0 0 Washer-Clothes 6 0 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet-Toilet 6 0 0 2 12 2 12 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 15 37 15 37 Current Fixture Value 37 divided by 16= 2.313 Current EDU 1 EDU= $5,300.00 Previous Fixture Value 0 divided by 16= 0.000 Previous EDU Change 37 divided by 16= 2.313 over (under) $ 12,243.00 Enter EDU Change Here 2.310 * *Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. Notes: Authorized Name/Signature: Dianna Howse Date: 5/1/2017 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. I:\Building\Sewer Tally\SewerTal]ySheet_5300_070116.xlsx