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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action l¢ t- 3-< l: ° c, v
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD V 0 1
Building Division /d/.P.57cP --
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner 112LApplicant ❑ Contractor ❑ City Staff
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REFUND OR Name:
INVOICE TO: (Business or Individual) h 0149 ory
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Mailing Address: 103 P)troot I Suite. S\D
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Phone No.: Q (.60 17-1100
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
jam. CANCEL/VOID PERMIT APPLICATION.
!_r REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
IIII INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CON I'H.ACTOR ON PERMIT (do not cancel permit).
Permit#: ,.�.1 �� t. ! itlli://e2r7/7-4/70
Site Address or Parcel#: /31121 SvA) lbea,co phis✓, -"tryaCe_
Project Name: Rwe rTo rA.ce.. tJ o tkwes+ -
Subdivision Name: 12.0ex Te,watt, Lot#: 2)4
EXPLANATION: !,' �.__� ► , II IIII. • '.[' _
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Signature: Date: /161/Z00
Print Name: - j, , dai
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorie 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 / 2X /, BR4,64
Refund Processed: D /2.5 / By jam'. Invoice Processed: Date By
Permit Canceled: Date i/ By •.' 'arcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_d9231 .doc
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111
TIGARD
City of Tigard
November 1, 2018
Polygon WLH,LLC
Attn: Angela Grajewski
109 East 13th St
Vancouver,WA 98660
Re: Permit No. MST2017-00188 017-00170
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13427 SW Beach Plum Ter
Project Name: River Terrace Northwest,Lot 24
Job No.: N/A
Refund Method: ® Check#230281 in the amount of$39,131.12.
❑ Credit card"return"receipt in the amount of$ .
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 permit was resubmitted under a new plan
(MST2018-00003 &SWR2018-00004). Refund 100% of permit fees/SDC fees and 80% of
plan review fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
dle -4441.7e7.4e____
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
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGAARD
Project Name: River Terrace Northwest, Lot 24
Site Address: 13427 SW BEACH PLUM TER .6'— i-e Af'Z
Receipt Number: 421257 - 01/25/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2017-00170 $-5,335.00
Total: $-5,335.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 230281 DHOWSE 01/25/2019 $-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
III13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
TI ARI.)
Project Name: River Terrace Northwest, Lot 24
Site Address: 13427 SW BEACH PLUM TER t9&/6-/469-4---
Receipt
iV'9---Receipt Number: 414051 - 11/21/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2017-00170 Sewer Connection Fee 500-0000-25500 / $5,300.00
SWR2017-00170 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 71844 DHOWSE 11/21/2017 $5,335.00
Payor: Polygon WLH, LLC
Total Payments: $5,335.00
Balance Due: $0.00
Page 1 of 1
r , CITY OF TIGARD SEWER CONNECTION PERMIT
114
Isf COMMUNITY DEVELOPMENT Permit#: SWR2017-00170
TIGARD13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/21/2017
Parcel: 2S106DB02400
Jurisdiction: Tigard
Site address: 13427 SW BEACH PLUM TER
Project: River Terrace Northwest,Lot 24 Subdivision: RIVER TERRACE NORTHWEST Lot: 24
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: 602-694-4031
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 11/21/2017 $5,300.00
Type of Use: SF Sewer Inspection-Residential 11/21/2017 $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. 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: 0(9 r
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.