Permit (149) CITY OF TIGARD MASTER PERMIT
11111
II '- COMMUNITY DEVELOPMENT Permit#: MST2018-00089
T[GA Ft D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/11/2018
Parcel: 1 S 135BD02200
Jurisdiction: Tigard
Site address: 9572 SW ANNA BELLE CT
Subdivision: ASH CREEK VILLAGE Lot: 8
Project: Ash Creek Village, Lot 8
Project Description: New SF.
BUILDING
Floor Areas Required Setbacks Required
Stories: 3 Bedrooms: 4 First: 446 sf Basement: 0 sf Left: 3 Parking Spaces: 0
Height: 28 Bathrooms: 4 Second: 841 sf Garage: 360 sf Front: 15 Smoke
Dwelling Units: 1 Third: 881 sf Right: 3 Detectors: Yes
Total: 2168 sf Value: $263,059.20 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 4 Washing Mach: 1 Laundry Trays: 0 Rain Drain: 1 Urinals: 0
Lavatories: 5 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Storm Sewer 100
Tubs/Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Drains: 0
Catch Basins: 0
Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value: 1 Bckflw Prevntr: 0
Drywell-Trench Drain: 0 Other Fixtures: 0
Other Fixture Units:
MECHANICAL
Fuel Types Air Conditioning: N Vent Fans: 5 Clothes Dryers: 1
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 4
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 1 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add!500 sf: 4 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
Audio&Stereo: N HVAC: N Security Alarm: N Vaccuum System: N Garage Opener: N All
Other: N Other Description: Ecompasing: Y
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
NEW SF VB R-3 2168
Owner: Contractor:
SAGE BUILT HOMES LLC SAGE BUILT HOMES Required Items and Reports(Conditions)
1815 NW 169TH PL STE 1040 1815 NW 168TH PLACE 1 Ersn Cntrl 503-639-4175
BEAVERTON,OR 97006 BEAVERTON,OR 97006 2 fire rated eave
PHONE: PHONE: 971-221-4597
FAX: 503-533-5164
Total Fees: $30,031.05
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 m obtain a cop • •- -s or direct questions to OUNC by calli 03 7 or 1.800.332.2344.
Issued By: ����.f�fL..h�_._-. ..,---- (1 —C-- --'C
Signature:
Ca . ' 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.
Building Permit Application
Residential RECEIVE1 FOR( FFICE: l SE O\Ll
• City Of Tigard Received
Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 MAR 2018 P an Revie i� ! /'1 'TD1�'� �
Phone: 503.718.2439 Fax: 503.598.1960 Date/B : ')a1;) 6 Other Permit: ar...)s
T f cI R p Inspection Line: 503.639.4175 CITY of TIGARD Date Ready/By: Juris: ® See 'age 2 for
Internet: www.tigard-or.gov SUIL^ Ip G OIt3I O otifi-•. ethod: /
/r ` 7 C Supplemental Information
��I
®New construction 0 Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
��{ Y-O,CO ON work indicated on this application.
® 1-and 2-family dwelling 0 Commercial/industrial Valuation: $
a 6 3, Us' 9 -I)
❑Accessory building 0 Multi-family Number of bedrooms: 4
❑Master builder 0 Other: Number of bathrooms: -3.q if
7 Total number of floors: 3�
Job site address:9572 SW Anna Belle Ct New dwelling area: 2168 square feet
City/State/ZIP:Tigard Oregon Garage/carport area: 360 square feet Q g f
Suite/bldg./apt.no.: Project name:Ash Creek Covered porch area: square feet$4 1
Cross street/directions to job site: Deck area: 24 square feet Li(J_6
Other structure area: square feet ��
, 3ATA:COMMERCIAL-USE E' E IST
Subdivision:Ash Creek I Lot no.:8 Permit fees*are based on the value of the work performed.
Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
O % work indicated on this application.
New Residential Construction Valuation: $
Existing building area: square feet
New building area: square feet
' •►e tom r '0,10414 Number of stories:
Name:Sage Built Homes Type of construction:
Address:1815 NW 169th Place Occupancy groups:
City/State/ZIP:Beaverton Oregon 97006 Existing:
Phone:(971)221-4597 Fax:( ) New:
::::;',/,7,:5;,:,'",,
APPLICANT,
Business name:Same As Above
E
Structural plan review fee(or deposit):
Contact name:Alex Rodriguez
Address:Same As Above
FLS plan review fee(if applicable):
City/State/ZIP: Total fees due upon application:
Phone:(971)336-6911 Fax::( ) Amount received:
P
E-mail:Planning@sagebuilthomesllc.com
HOOTO ` TAT SO ' N� L ,.
' P Commercial and residential prescriptive installation of
. . ; off'
,� , :. -,,,,,,<-, ;., � -„ , , roof-top mounted Photovoltaic Solar Panel System.
Business name: �" ,tSubmit two(2)sets of roof plan with connection details
��e 'J"e„,,//� i } and fire department access,along with the 2010 Oregon
Address: Solar Installation Specialty Code checklist.
City/State/ZIP: Permit Fee(includes plan review $180.00
and administrative fees):
Phone:( ) Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.:
Total fee due upon application: $201.60
Authorized signature: This permit application expires if a permit is not obtained
' ( within 180 days after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry
Print name:Ben Cooper Date:3/5/18
Service Board.
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Building Permit Application Checklist
One- and Two-Family Dwelling FOR OFFICE I.SE ONE.t
w
City of Tigard Received PermitNo.:
Datn 13125 SW Hall Blvd.,Tigard,OR 97223 Y
1111 I g Associated permits:
Phone: 503.718.2439 Fax: 503.598.1960
0 Electrical 0 Plumbing 0 Mechanical
T 1 G A R D 24-Hour Inspection Line: 503.639.4175
Internet: www.tigard-or.gov ❑ e'er:
THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW l es No N/`k
1 Land use actions completed. See jurisdiction criteria for concurrent reviews. 0 ❑ 0
2 Zoning. Flood plain,solar balance points,seismic soils designation,historic district,etc. 0 0 0
3 Verification of approved plat/lot. 0 0 0
4 Fire district approval required. Name of district: 0 0 0
5 Septic system permit or authorization for remodel. Existing system capacity . 0 0 0
6 Sewer permit, '
0
0
7 Water district approval.
0 0 0
8 Soils report. Must carry original applicable stamp and signature on file or with application. 0 0 0
9 Erosion control n plan 0 permit required. Include drainage-way protection,silt fence design and location of catch- 0 0 0
basin protection,etc.
10 3 Complete sets of legible plans. Must be drawn to scale,showing conformance to applicable local and state 0 0 0
building codes. Lateral design details and connections must be incorporated into the plans or on a separate full-size
sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if
' copyright violations exist.
11' Site/plot plan drawn to scale. The plan must show lot and building setback dimensions;property corner elevations(if 0 0 0
there is more than a 4-ft.elevation differential,plan must show contour lines at 2-ft.intervals);location of easements
and driveway;footprint of structure(including decks);location of wells/septic systems;utility locations;direction
indicator;lot area;building coverage area;percentage of coverage;impervious area;existing structures on site;and
surface drainage.
12 Foundation plan. Show dimensions,anchor bolts,any hold-downs and reinforcing pads,connection details,vent size 0 0 0
and location.
13 Floor plans. Show all dimensions,room identification,window size,location of smoke detectors,water heater, 0 0 0
furnace,ventilation fans,plumbing fixtures,balconies and decks 30 inches above grade,etc.
14 Cross section(s)and details. Show all framing-member sizes and spacing such as floor beams,headers,joists,sub- 0 ❑ 0
floor,wall construction,roof construction. More than one cross section may be required to clearly portray
construction. Show details of all wall and roof sheathing,roofing,roof slope,ceiling height,siding material,footings
and foundation,stairs,fireplace construction,thermal insulation,etc.
15 Elevation views. Provide elevations for new construction;minimum of two elevations for additions and remodels. 0 0 0
Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope.
Full-size sheet addendums showing foundation elevations with cross references are acceptable.
16 Wall bracing(prescriptive path)and/or lateral analysis plans. Must indicate details and locations;for non- 0 0 0
prescriptive path analysis provide specifications and calculations to engineering standards.
17 Floor/roof framing. Provide plans for all floors/roof assemblies,indicating member sizing,spacing,and bearing 0 0 0
locations. Show attic ventilation.
18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered 0 0 0
systems,see item 22,"Engineer's calculations."
19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists 0 0 0
over 10 feet long and/or any beam/joist carrying a non-uniform load.
20 Manufactured floor/roof truss design details. 0 0 0
21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas-piping schematic is required 0 ❑ 0
for four or more appliances.
22 Engineer's calculations. When required or provided,(i.e.,shear wall,roof truss)shall be stamped by an engineer or 0 0 0
architect licensed in Ore.on and shall be shown to be a..licable to the .ro'ect under review.
JURISDICTIONAL SPECIFICS
23 Three(3)site plans are required for Item 11 above. Site plans must be 8-1/2"x 11"or 11"x 17". 0 0 0
24 Two(2)sets each are required for Items 16, 19,20 and 22 above. 0 0 0
25 Building plans shall not contain red lines or tape-ons. "Mirrored"building plans will not be accepted. 0 0 0
26 "Reversed"building plans must meet criteria outlined in the Permit&System Development Fees document. 0 0 0
27 "Drawn to scale"indicates standard architect or engineer scale. 0 0 0
28 Site plan to include tree size,type and location per approved project street tree plan(if applicable),and City of Tigard 0 0 0
Street Tree List.
29 Site plan to include trees and tree protection measures as required by conditions of approval. Tree locations,driplines, 0 0 0
and protection measures must be drawn to scale and must include the project arborist's signature of approval.
30 A Clean Water Services'Sensitive Area Pre-Screening Site Assessment form is required for all building additions, 0 0 0
including decks,patio covers(over non-impervious surface)and accessory structures to existing residential dwellings
on a lot of record approved prior to September 9, 1995.
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
Mechanical Permit Application FOR OFFI('E FOSE()NIA
Cityof Tigard EES �� • � aid di
g Permit No.:Ago, `�
13125 SW Hall Blvd., Fax: OR 97223
Phone: 503.718.2439 Fax: 503.598.1960 1 Other Permit:
T I G A RD Inspection Line: 503.639.4175 MAR I 0 I 'i-'e Ready/By: luris: H See page 2 for
Internet: www.tigard-or.gov • • ethod: Supplemental Information
CITY' OF it t. :rM
A.
YyX �. r :✓ A 69r� .
, aeg
,.. ,,,r.- r . .,. �1 3• B4uft",,,,J ' 19I ',i . 091
, 0,1 :'1 M.I;.il ,
Mechanical permit fees*are based on the value of the work
®New construction El Addition/alteration/replacement performed.Indicate the value(rounded to the nearest dollar)of all
0 Demolition 0 Other: mechanical materials,equipment,labor,overhead,and profit.
W h,,,. r " '°A Y . £o 'i4. jo f 7 Value:$
® 1-and 2-family dwelling 0 Commercial/industrial El Accessory building For special information use checklist.
0 Multi-family 0 Master builder ❑Other: Description Qty. Ea. Total
Ogf op Heating/cooling:
Air conditioning 1 46.75 46.75
Job site address:9572 SW Anna Belle Ct Furnace 100,000 BTU(ducts/vents) 1 46.75 46.75
City/State/ZIP:Tigard Oregon Furnace 100,000+BTU(ducts/vents) 54.91
Suite/bldg./apt.no.: Project name:Ash Creek
Heat pump 61.06
Duct work 23.32
Cross street/directions to job site: Hydronic hot water system 23.32
Residential boiler(radiator or
hydronic) 23.32
Unit heaters(fuel-type,not electric), ,
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 23.32
Subdivision:Ash Creek Lot no.:8 Other: 23.32
Other fuel appliances:
Tax map/parcel no.: Water heater 1 23.32 23.32
w
6*- `; Gas fireplace/insert 1 33.39 33.39
Flue vent for water heater or gas
New Residential Construction fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23.32' Other: 23.32
Environmental exhaust and ventilation:
Name:Sage Built Homes Range hood/other kitchen
equipment 1 33.39 33.39
Address: 1815 NW 169th Place
Clothes dryer exhaust 1 33.39 33.39
City/State/ZIP:Beaverton Oregon 97006 Single-duct exhaust(bathrooms,
toilet compartments,utility rooms) 5 23.32 116.60
Phone:(971)221-4597 Fax:( ) Attic/crawlspace fans 1 23.32 23.32
,,,,,,:;.,";.,:,?;:,,,,;;;', ;o:1�` 00 ;RS( Other: 23.32
Business name:Same As Above Fuel piping:
$14.15 for first four;$4.03 for each additional
Contact name:Alex Rodriguez Furnace,etc.
Address:Same As Above Gas heat pump
Wall/suspended/unit heater
City/State/ZIP: Water heater
Phone:(971)336-6911 Fax::( ) Fireplace
Range
E-mail:Planning@sagebuilthomeslIc.com Barbecue
.. ., V` . F , i ` ;.. , Clothes dryer(gas)
Business name:All Time Heating&Cooling Other
�+ F *
Address:PO Box 1341 .. ..F.
Subtotal
City/State/ZIP:Lake Oswego,OR 97035 Minimum permit fee($90.00)
Plan review(25%of permit fee)
Phone:(503)208-2276 Fax:( ) State surcharge(12%of permit fee)
CCB lick ) it GG(T�j i- TOTAL PERMIT FEE
This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: ' Fee methodology set by Tri-County Building Industry Service Board
Print name:Ben Cooper Date:3/5/18
I:\Building\Permits\MEC_PermitApp_040113.doc 440-4617T(11/02/COM/WEB)
Mechanical Permit Application - City of Tigard
Page 2 - Supplemental Information
Commercial& Multi Family Fee Schedule:
$0.00 to$500.00 Minimum fee$69.06
$500.01 to$5,000.00 $69.06 for the first$500.00 and
$3.07 for each additional$100.00 or
fraction thereof,to and including
$5,000.00.
$5,000.01 to$10,000.00 $207.21 for the first$5,000.00 and
$2.81 for each additional$100.00 or
fraction thereof,to and including
$10,000.00.
$10,000.01 to$50,000.00 $347.71 for the first$10,000.00 and
$2.54 for each additional$100.00 or
fraction thereof,to and including
$50,000.00.
$50,000.01 to$100,000.00 $1,363.71 for the first$50,000.00 and
$2.49 for each additional$100.00 or
fraction thereof,to and including
$100,000.00.
$100,000.01 and up $2,608.71 for the first$100,000.00 and
$2.92 for each additional$100.00 or
fraction thereof
Note: All new commercial buildings require 2 sets of plans.
I:\Building\Permits\MEC_PermitApp_040113.doc 2
. Electrical Permit Application d
Y City of Tigard RECEIVPDate/By. Permit#:
II "t 13125 SW Hall Blvd.,Tigard,OR 97223 Review ;^gat vu t t z)rf
■ Related Permit K:
Phone: 503.718.2439 Fax: 503.598.1960 MAR
?� 7 l mtg ;
YIHR e� ( 1 Y
I I c l Inspection Line: 503.639.4175 Ready Date/By: rur+s: to See Page 2 for
Internet: www.tigard-or.gov CITY RAiem 1/Method: Supplemental Information
� C)€- 1 I(,-?r„t
TYPE O>r w BUILDING nivisoOt PLAN tEVIEW t
®New construction 0 Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition ❑Other:
where the available fault current 0 Marinas and boatyards,
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at ISO volts or ❑Floating buildings
® 1-and 2-family dwelling 0 Commercial/industrial ❑Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
❑Multi-family 0 Master builder 0 Other: 0 Fires for all other installations. nstaings.
pump,
p. 0 Installation of I 50 KVA or
.JOB SITE INFORMATION AND LOCATION 0 Emergency system. larger separately derived
Job#: Job site address: 9572 SW Anna Belle Ct ❑Addition of new motor load of system.
t00HP or more, ❑``A""E>,"1-2""1-3„
City/State/ZIP:Tigard Oregon ❑Six or more residential units. occupancy.
❑Health-care facilities. 0 Recreational vehicle parks,
Suite/bldg./apt.#: Project name:Ash Creek 0 Hazardous locations 0 Supply voltage for more than
❑Service or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: - FEE SCHEDULE
..Description I..Qty. I Each J1 Total F.
New residential single-or multi-family dwelling unit.
Subdivision:Ash Creek Lot#: 8 _Includes attached garage.
Tax map/parcel#: 1,000 sqftor less 168.54_ 4
Ea,add'(500 sq,fl or portion 33.92 1
DESCRIPTION OF WORK -Limited energy, .
residential 75.00 2
New Residential Construction (with above sq.ft)
Limited energy,multi-family
75.00 2
residential(with above sq.ft,)
�y PROPERTY OWNER Renewable Energy El See Pale 2
0 TENANT Services or feeders installation,,alteration,and/or relocation
Name:Sage Built Homes LLC 200 amps or less 1 100 70 100.70 2
Address:1815 nw 169TH Place Suite 1040 _201 amps to 400 amps 133.56 2
401 amps to 600 amps 200.34 2
City/State/ZIP:Beaverton Oregon 97006 _601 amps to 1,000 amps 301.04 2
Phone:(971)221-4597 Fax:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not _200 amps or less 59,36 1
intended for sale, lease,rent,or exchange,according to ORS 447,449,670,and 701. ^201 amps to 400 amps 125,08~ 2
Owner signature: Date: 401 amps to 599 amps 168,54 2
® APPLICANT 1 Q CONTACT PERSON 'Branch circuits—new,alteration,or extension.3rer panel
A Fee for branch circuits with
Business name:Same As Above above service or feeder fee,
742 2
each branch circuit
Contact name:Alex Rodriguez B.Fee for branch circuits without
Address: service or feeder fee,first 56.18 2
branch circuit
—
City/State/ZIP: Each add'I branch circuit 7,42 2
—Miscellaneous(service or feeder not included)
Phone:(971)336-6911 Fax::( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email:Planning@sagebuilthomesllc.com ^Reconnect only 67.842
CONTRACTOR Pump or irrigation circle 67.84 y 2
Business name:Ross Electric Sign or outline lighting 67,84 2
Signal circuit(s)or limited-energy
Address:2870 SE 75th Ave 203 panel,alteration,or extension. 0 See Page 2 2
City/State/ZIP:Hillsboro Oregon 97123 Each additional inspection over allowable in any of the above
Additional inspection(1 hr min) 66.25/hr
Phone:(503)642-2800 Fax:( ) Investigation(1 hr min) 90.00/hr
^
Email: ( v /il
/` Industrial plant(l hr min) 78.18/hr
[ ` Inspections for which no fee is 90.00/hr
CCB Lie.: 157891 Electrical Lie.: 34-436C [ Suprv.Lic..Y., Sspecifically listed(1/i hr min)
5- 4, _ ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: A. Subtotal:
Print name: Stephen Ross 5 jr ,it,‘ o r Date: 0 Plan Review Required(25%of permit fee).
State surcharge(12%of permit fee):
Authorized signature: 0 - Or TOTAL PERMIT FEE:
This permit application expires if a permit is not obtained within 180
Print name: Senn oope,�" Date: 2/1/2018 days after it has been accepted as complete.
t • Number of inspections allowed per permit.
I\BuildingTermits\ELC_Pntni1App_ELR ERE.doe Rev 06/17/2015 440-46151(11105/COM/WEB
Plumbing Permit Application
Building Fixtures = 4� °�
g Holz oFFICL Iisl: oNL1
• City of Tigard Received
g Permit No.:
13125 SW Hall Blvd.,Tigard,OR 97223 n�Q Date/By: 415-772743,L,)�
Phone: 503.718.2439 Fax: 503.598.1960 1�AR °" r_ 0 Plan Review V
Date/By: Other Permit No.:
T I G A R D Inspection Line: 503.639.4175a Read/B Juris: H See Page 2 for
Internet www.tigard-or.gov CIT,S - r, '�°l ed/Method: Supplemental Information
®New construction 0 Demolition For special information use checklist
Description I Qty. Ea. Total
❑Addition/alteration/replacement 0 Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
CATEGORY Of cosnw O , SFR(1)bath 312.70
® 1-and 2-family dwelling 0Commercial/industrial SFR(2)bath 437.78
❑Accessory building El Multi-family SFR(3)bath x 500.32 500.32
Each additional bath/kitchen 1 25.02 25.02
❑Master builder 0 Other:
Fire sprinkler( sq.ft.) Page 2
4,011 SITE INFORMATION AND I.. ,/ ON , Site utilities:
Job site address:9572 SW Anna Belle Ct Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard Oregon
Footing drain(no.linear ft.: ) Page 2
Suite/bldg./apt.no.: I Project name:Ash Creek Manufactured home utilities 50.03
Cross street/directions to job site: Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.: ) Page 2
Storm sewer(no.linear ft.: ) Page 2
Water service(no.linear ft.: ) Page 2
Subdivision:Ash Creek I Lot no.:8 Fixture or item:
Tax map/parcel no.: Backflow preventer 1 31.27 31.27
B1 1 TIIN OF W'1.6, Backwater valve 12.51
washer Clothesash 1 25.02 25.02
Dishwasher 1 25.02 25.02
New Residential Construction Drinking fountain 25.02
Ejectors/sump 25.02
1 EoP 'Iy OWNER Expansion tank 12.51
Name:Sage Built Homes LLC Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address:1815 NW 169th Place
' Garbage disposal 1 25.02 25.02
City/State/ZIP:Beaverton Oregon 97006 Hose bib 2 25.02 25.02
Phone:(971)221-4597 Fax:( ) Ice maker 12.51
s� AtGmo ', Af F1S Interceptor/grease trap 25.02
Business name:Same As Above Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Alex Rodriguez
Roof drain(commercial) 12.51
Address:Same As Above Sink/basin/lavatory 6 25.02 150.12
City/State/ZIP: Solar units(potable water) 62.54
Phone:(971)336-6911 Fax: :( ) Tub/shower/shower pan 2 12.51 37.53
Urinal
25.02 Planning@sagebuilthomesllc.com
C` NTRkR Water closet 25.02
.O
Water heater 1 37.52 37.52
Business name:Edwards Mullen Plumbing Water piping/DWV 56.29
Address:1601 A Se River Rd Other: 25.02
City/State/ZIP:Hillsboro Oregon 97123 Subtotal
Phone:(503)628-3560 Fax:( ) 7 ji/ Minimum permit fee: $72.50
) Plan review (25%of permit fee)
� C/
CCB Lic.:92689 PI s.:'ng Lic.no.:
State surcharge(12%of permit fee)
Authorized signature: 1 0 ,Iii, , TOTAL PERMIT FEE
Print name:Ben Cooper Date:3/5/18 This permit application expires if a permit is not obtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tri-County Building Industry Service Board.
I\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(10/02/COM/WEB)
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
•
Fee Schedule: Residentialre Suppression Systems:
Q iea
Footing drain-1a 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 � Pe " _
$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
t2tj. leed�l
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$100.00 or fraction thereof.
Subtotal:
Commercial Fixture Work:
Are you capping,adding or replacing fixtures? If"yes",
please indicate work performed by fixture. Failure to
accurately report fixtures could result in increased sewer fees*.
Quantity by Fixture Type ,; or Pl11mbing I _. N, tion$
Fixture Type for Replace! Plan review is required for any of the following.
Work Performed: Capped ` Added Relocate
Baptistry/Font Please check all that apply.
Bath Tub/Shower
D Any new commercial building with water service 2"and
Jacuzzi/Whirlpool 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
Cuspidor/Water Aspiratoras defined in OAR918-780-0040.
Dishwasher -Commercial ❑' Medical gas and vacuum systems for health care facilities.
-Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain 0 Any complex structure as defined in OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" Submit 2 sets of plans with any of the above.
Car Wash Drain
Garbage Domestic-non-food
0 Isometric or riser diagram is required for new buildings
Disposal -Domestic-food related that meet the qualifications above.
-Commercial-food related
-Industrial-food related
Ice Mach./Refrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav -Non-food related
-Bradley
-Commercial-food related
-Service
Swimming Pool Filter *Note: If the fixture work under this permit results in an
Washer-Clothes
Water Extractor increase of sewer EDIJs,a sewer permit will be issued and
Water Closet-Toilet fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
S:\Sage Built\Purchasing&Planning\Subdivisions\Ash Creek\Plans\Lot 8Applications\Plumbing.doc
•
City of Tigard
■ u COMMUNITY DEVELOPMENT DEPARTMENT
111111
T I G A R D Building Permit Review — Residential
Building Permit #: Ai' j l jx
Site Address: ' -2(0 fir,g/lC2,90-1--
---,.
Project Name: Lot #:
(New dwelling=subdivision name;Addictor Alteration=last name of owner)
Planning Review
Proposal: / v c-``�
Verify site address/suite#exists and activ in permit system.
0 River Terrace Neighborhood: 'L1J No 0 Yes,See River Terrace Review Addendum Attached
Sit, Plan Elements:
ree(3)copies of site plan �I;`� sting structures on site
to plan must be on 8-1/2"x 11"or 11 x 17"paper ►n ootprint of new structure(including decks)with finished
rawn to scale(standard architect or engineer scale) or elevations
rth arrow . "ty locations&easements(required for new and additions)
SLI to address,project or subdivision name and lot number Sidewalk/driveway approach
pplicant information(name and phone number) ‘I1 I':A++cation of wells/septic systems
VA Lot dimensions and building setback dimensions PP '° "sting trees to be retained with drip line,and tree
it 1 uare footage of buildings to be demolished ,rotection measures
VA Lot area,building coverage area,percentage of coverage and ,!A S�eet tree size,type and location
)rnpervious area(applicable if R-7,R-12,R-25&R-40) L.1Y5treet names
Property corner elevations (2 foot contour lines if more than >1,000 sf of impervious area created or repla Yes ❑No
4 foot differential) If es,is a storm water •uali facili shown? Yes ENO
Ililklean Water Services—Service Provider Let r(lot platted prior to 9/10/1995):
il;, wired: ❑ Yes,applicant was notified .■ No Received: ❑ Yes Cl No
Peugblic Facilitie mprovement (PFI) Permit: ,_� 7)p) Q Jam" 9O/
Required: Yes,applicant was notified CI No Applied For: Yes ❑ No,stop intake
4and Use Case#: Phe j‘ 60 0 l i --Ct( )/--a)063
0/Zoning: P— 1-2_ (pb )
equired Setbacks: Front i. "-- Rear /c Side Street Side 0, Garage t 0
0/Landscape Requirement: ...2
Vf Coverage Maximum: er) cy.
woilding Height: Maximum Height 1 Actual Height J 1e, n
*grisual Clearance
ensitive Lands:
Yes CI Type _
rca$7
Urban Forestry Plan
0 Conditions "Met"hc
r to issuance/of building permit
CAT
Notes: � ,-C1/N49.--// ,1, / - (2Y-- ) fhll7_ fix1 ,L4.e�
❑ Approved By Planning: _ —4111111111111111r7 Date: 5 g 0
Revisions (after Building Submittal only) Reviewer Date
Revision 1: 0 Approved 0 Not Approved
Revision 2: ❑ Approved ❑ Not Approved
Revision 3: 0 Approved ❑ Not Approved
I:\Building\Fonns\BldgPermitRvw_RES 061417.docx
Building Permit Submittal
Original Submittal Date: 3//51/y
Site Plans: # 3
Building Plans: #
Building Permit#: 2:1
mer building permit�#above.
Workflow Routing: Er anning 1E1.- gineering ermit Coordinator ceding
Workflow Sign-off: l -8tgn-off for Planning(include notes from planning review)
Route Application Documents: El.- ngineering: (1) copy of permit application, (1) site plan, (1) building plan and
origin: al plan review routing form.
'Building: original permit application, site plans,building plans,engineer and
beam calculations and trust details,if applicable,etc.
Notes: :...e).„
By Permit Technician:
..,- :< '..--'6.---: e--y - Date: 04.4,
Engineering Review
Slope at building pad: l
Conditions "Met"prior to is ance of building permit
❑ Easements (encroachments)per engineering conditions of approval and plat
Water Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: ❑ Yes ❑ - o
Assess Water Quantity Fee in-lieu: ❑ Yes ❑ o
LIDA Facility on lot: El Yes ❑ No
❑ Final Plat Recorded:
❑ NOT Approved by Engineering: Date:
Notes:
❑ Approved by Engineering: iff4-4 .D Date: 0rite,
Revisions (after Building Submittal only) Reviewer Date
Revision 1: ❑ Approved ❑ Not Approved
Revision 2: ❑ Approved Cl Not Approved
Revision 3: ❑ Approved ❑ Not Approved
Permit Coordinator Review
❑ Conditions "Met"prior to issuance of building permit
< /117
Approved,NOT Released: ,,r'I jj 0 t-— Date: �
3 t f t 1------
Notes:
Revisions (after Building Submittal only)
Revision Notice 1: Date Sent to Applicant:
Revision Notice 2: Date Sent to Applicant:
Revision Notice 3: Date Sent to Applicant:
'IDC Fees Entered: Wash Co Trans Dev Tax: r71qes ❑ N/A
Tigard Trans SDC: Yes ❑ N/A
Parks SDC: V'Yes ❑ N/A
LIDA ❑ Yes -N/A
OK to Issue Permit
Approved by Permit Coordinator: /*41Date: 7t 1
I:\Building\Forms\BldgPermitRvw_RES_010118.docx
Plumbing Permit Application
Building Fixtures FOR 0121:1(4: FSE ()NI.)
Received
Cityof Tigard
1 Permit➢D6.r�/ C ';
131SW HallllBlvd.,Tigard,OR 97203U �9 r n Date/By: z �jjl /�� ��
;� . ®® pa ��y r-} Plan Review Other Permit No.:
Phone: 503.718 2439 Fax: 503.598}11611 Date/By:
I 1 1,t Inspection Line: 503.639.4175 Date Ready/By Saris: H See Page 2 for
Internet: www.tigard-or.gov2. NotifiedlMetk�d: Supplemental Information
,. . t to .�, °Y.. �ie ,` n d ' .' 0.rt i �i4 h`1m4i
®New construction 0 Demolition ! 11,/����� For special information use checklist
Description Qty. Ea. Total
0 Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
r.�t % - _`I ' f t a ,' E SFR(1)bath
312.70
® 1-and 2-family dwelling ❑Commercial/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
0 Other: Fire sprinkler( sq.ft.) Page 2
,e tt` € t f 1 f t ,. ' Site utilities:
','4 x „ a,4'
Job site address:9572 SW Anna Belle Ct Catch basin or area drain 18.76
Drywell,leach line,or trench drain 18.76
City/State/ZIP:Tigard,Oregon
Footing drain(no.linear ft:_) Page 2
Suite/bldg./apt.no.: I Project name:Ash Creek Village Manufactured home utilities 50.03
Cross street/directions to job site:SW 95th Avenue Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.:_) Page 2
Water service(no.linear ft.:_) Page 2
Subdivision:Ash Creek Village I Lot: 8 Fixture or item:
Tax map/parcel no.: Backflow preventerval12.51
31.27
r2 ,' . Backwater ve
Clothes washer 25.02
New residential construction/Plumbing contractor revision Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Expansion tank 12.51
'r :° �� Ple ,1 P
Name:Sage Built Homes,LLC. Fixture/sewer cap 25.02
Floor drain/floor sink/hub 25.02
Address: 1815 NW 169th Place,Suite 1040
Garbage disposal 25.02
City/State/ZIP:Beaverton,Oregon Hose bib 25.02
Phone:(971)221-4597 Fax:( ) Ice maker 12.51
%":.:,,A,","' a r$14 CONT "` ® Interceptor/grease trap 25.02
Business name:Sage Built Homes,LLC. Medical gas(value:$ ) Page 2
Primer 12.51
Contact name:Ben Cooper
Roof drain(commercial) 12.51
Address:Same as above Sink/basin lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:(971)258-6658 Fax: :( ) Tub/shower/shower pan 12.51
E-mail:planning*,sagebuilthomeslle.com Urinal 25.02
x
Water closet 25.02
p
>.' ;' s . CfoR ' z
"' tt '°rte Water heater 37.52
Business name:Max Plumbing Service Inc Water piping/DWV 56.29
Address:PO BOX 230674 97281 Other: 25.02
City/State/ZIP: Tigard,OR 97281 Subtotal
Phone:(971)-275-0198 Fax:( ) Minimum permit fee: $72.50
CCB Lie.: 205392 Plumbing Lic.no.: Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized signature: ARMFEE
Print name:Ben Cooper Date:7/23/2018 This permit application expires if a permit iLs notPEobtained within 180 days
after it has been accepted as complete.
*Fee methodology set by Tr-County Building Industry Service Board.
440-4616T(10/02/COM/WEB)
I\Building\Permits\PLMU-PermitApp.doe 10/01/09
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: Residential Fire Su i .ression S stems:
.r i 4 +z Nf gN.
Footing drain-1s`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 S stems:
Water Service-each additional 100' 37.52 ' r <<.�` ��Yi
-`�
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
��' ewojawgit .i 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 char:e-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 char:e-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*.
Quantity by Fixture Typea• lull>tr[t7:4:1:17. t1Q
Fixture Type for Replace) r "
Plan review is required for any of the following.
Work Performed: Capped Added Relocate
Baptistry/Font Please check all that apply.
Bath -Tub/Shower ❑ Any new commercial building with water service 2"and
-Jacuzzi/Whirlpool 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
Cuspidor/Water Aspirator as defined in OAR918-780-0040.
Dishwasher -Commercial ❑ Medical gas and vacuum systems for health care facilities.
-Domestic 0 Any multipurpose fire sprinkler system.
Drinking Fountain 0 Any complex structure as defined in OAR918-780-0040.
Eye Wash
Floor Drain/sink -2" Submit 2 sets of plans with any of the above.
-3"
4„ r .,�o-p
IsomletricAra* ,er Diagram ry
Car Wash Drain
Garbage -Domestic-non-food 0 Isometric or riser diagram is required for new buildings
Disposal -Domestic-food related that meet the qualifications above.
-Commercial-food related
-Industrial-food related
Ice Mach./Refrig.Drains
Oil Separator(Gas Station) Comments regarding fixture work:
Rec.Vehicle Dump Station
Shower -Gang
-Stall
Sink/Lav -Non-food related
-Bradley
-Commercial-food related
-Service
Swimming 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 fees assessed for the sewer increase must be paid before the
Urinal plumbing permit can be issued.
Other Fixtures:
C:\Users\kylie\Downloads\PLMF_PermitApp.doc 2
FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information.
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Transmittal Letter
T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: DATE RECEIVED:
DEPT: BUILDING DIVISION RECEIVED
I AUG 2 3 2018
FROM:
Ci i"Y OF 1 1GARD
COMPANY: r 'e/ A` �� D5D 3 U( IpMOON
PHONE: q `
1 BY:
RE: q5rt bop& ? p\ t w `J° 10-'0X?C)Fc
(Site Address) (Permit Number)
N C-rte,&. Lok-
(Project name or subdivision name and lot num er)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: Description: Copies Description:
Additional set(s) of plans. ✓ Revisions: C,6e."" A G6\6,-C9t,0
Cross section(s) and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
Other(explain):
REMARKS:
FOR O FIC USE ONLY
Routed to Permit Technic' . Date: 43 Z�j `R) Initials: hit—
Fees Due: ❑ Yes No Fee Descrip ion: Amount Due:
/Q•b(VL
$
Special
Instructions:
Reprint Permit(per PE): ❑ Yes o ❑ Done
Applicant Notified: Date: Initials:
I:\Building\Forms\TransmittalLetter-Revisions_061316.doc
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
9572 SW ANNA BELLE CT, TIGARD, OR, 97223 November 9, 2018 at
10:03:01 AM
Record Type: Record ID:
Residential - Master Permit MST2018-00089
Inspection Type: Inspector:
699 Mechanical final Jeremy Burrows
Result:
PASS
Comments:
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
9572 SW ANNA BELLE CT, TIGARD, OR, 97223 November 14, 2018 at
9:52:59 AM
Record Type: Record ID:
Residential - Master Permit MST2018-00089
Inspection Type: Inspector:
199 Electrical final Aaron Cillo-Gobel
Result:
PASS
Comments:
No A/C installed
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
9572 SW ANNA BELLE CT, TIGARD, OR, 97223 November 14, 2018 at
10:10:46 AM
Record Type: Record ID:
Residential - Master Permit MST2018-00089
Inspection Type: Inspector:
399 Plumbing final Aaron Cillo-Gobel
Result:
PASS
Comments:
Corrections completed.
Violation Summary:
Inspector Contractor
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223 Tel: 503.718.2439
Location: Inspection Date:
9572 SW ANNA BELLE CT, TIGARD, OR, 97223 November 19, 2018 at
9:41 :49 AM
Record Type: Record ID:
Residential - Master Permit MST2018-00089
Inspection Type: Inspector:
299 Final inspection Aaron Cillo-Gobel
Result:
PASS - CofO
Comments:
Final erosion control passed
Street tree certificate received
Moisture content form received
Moisture barrier acknowledgement form received
High efficiency lighting form received
Insulation certification verified
Blower door and/or duct seal test certificate received
C of 0 left on counter.
Violation Summary:
Inspector Contractor
1
FOR OFFICE USE ONLY—SITE ADDRESS:
This form is recognized by most building departments in the Tri-County area for transmitting information.
Please complete this form when submitting information for plan review responses and revisions.
This form and the information it provides helps the review process and response to your project.
III City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Transmittal Letter
, ,i i. r 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: DATE RECEIVED:
DEPT: BUILDING DIVISION
FROM: i3ex\ Cq. c JUN 13 2018
COMPANY: G` E_ Exr,,\ k- 146new c:-,--` ,.,,,,DBt,,,,, ,; ,,,,,.-'0N.
PHONE: qi I :l ,g -665f By:
RE: g577 SW Ayw 1iie . CAS- A5i-201g -ocoER
( ite Address) (Permit Number)
CIeIK 1-30i— 8
(Project name or subdivision name and lot number)
ATTACHED ARE THE FOLLOWING ITEMS:
Copies: Description: Copies: Description:
Additional set(s) of plans. Revisions: t /ak'ft„ s' , r. I •
Cross section(s)and details. Wall bracing and/or lateral analysis.
Floor/roof framing. Basement and retaining walls.
Beam calculations. Engineer's calculations.
Other(explain):
REMARKS:
FOR O7.,..USE ONLY
Routed to Perm.'`�e cian: Date: (k 2Q) Initials:Fees Due: ��Y E No Fee Descri do
Amount Due:
$
$
$
Special
Instructions:
Reprint Permit(per PE): [ Yes �o [ Done
Applicant Notified: _ Date: Ce(Lti(i5 Initials:a/
I:\Building\Forms\TransmittalLetter-Revisions 061316.doc
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 2 2 2018
Request for Permit Action CITY OF TIGARD
BUILDING DIVISION
t , ,i i, 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 ❑X Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
•
INVOICE TO: (Business or Individual) Sage Built Home
Mailing Address: 1815 NW 169th Place Suite#1040
City/State/Zip: Beaverton,OR 97006
Phone No.: 503-533-5167
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(1): '
•
❑ CANCEL/VOID PERMIT APPLICATION.
5 REFUND PERMIT 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#: MST2018-00089
Site Address or Parcel#: 9572 SW Anna Belle Ct
Project Name: Ash Creek Village
Subdivision Name: Ash Creek Lot#: 8
EXPLANATION: Requesting to remove A/C from permit and a refund
Signature: $¢yy e.ey 4.., Date: S/2 Zhe
Print Name: Ben Cooper 0
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
/ o!/G-- -� r/fie issa - A -/.l1///66- ,7Z 0,
Route to Sys Admin: Date By Route to Records: Date By
Refund Processed: Date "(le-/e- By Invoice Processed: Date By
Permit Canceled: Date 0 .%I�. By Parcel Ta$Added: Date By
I:\Building\Forms\RegPermitAction_112314.doc