Permit Support Document (21) City of Tigard • COMMUNITY DEVELOPMENT DEPARTM T '.
'I
Request for Permit Action
-5/24//7
TI G A 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 Ti uildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Q. Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: (i ^ J m�
INVOICE TO: (Business or Individual) '/�
Mailing Address: PD 0 be. 11 613
City/State/Zip: CrA y vas 9g66-4-
Phone
g66Phone No.: .360 - 7-?2 ' A46D
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copyof 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#: 51-L"--Re 17--DO/L-f
Site Address or Parcel#: 73.3/ -,/'�1.
Project Name: t` J '- j /S 11`7`Lr ,h't-
Subdivision Name: Lot#:
EXPLANATION: CC._U.:i 5-c.5k b C r>^ rie f c Jej
peuit.dt IA, 4u.. l td spa,"
Signature: - Date: 570
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date `i 3 1'7 By ,'s Route to Records: Date .2-C, /7 By
Refund Processed: Date JJ "9- By 44 Invoice Processed: Date By
Permit Canceled: Date /241/2 By arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09 314.d'oc
Is
i 11 • Tenant Name:Ways and Means Oyster HouseAccumulative Sewer Tally V 0 1 0
SWR#N/A
r l n 1,n Site Address: 7331 SW Bridgeport Rd PLM#2017-00145
Parcel#: 2S113AC01201
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 1 4 1 4
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 2 4 0 -2 -4
-3 inch 5 0 3 15 1 5 -2 -10
-4inch 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 1 1 1 1
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 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 0 0 0
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 2 6 2 6 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 1 6 0 -1 -6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 8 31 5 16 -3 -15
Current Fixture Value -15 divided by 16= -0.938 Current EDU 1 EDU= $5,300.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change -15 divided by 16= -0.938 over (under) $ (4,982.00)
Enter EDU Change Here -0.940 *
*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: ***CREDIT***REVISED SEWER TALLY 5/3/17:ADDED(1)COM DISHWASHER,(1)3"FLOOR DRAIN,(1)ICE MACHINE,
(2)SERVICE SINKS;RELOCATED(2)COMMERCIAL DISHWASHERS,(7)3"FLOOR DRAINS,(1)ICE MACHINE,AND(9)SERVICE SINKS.
Authorized Name/Signature:Debbie Adamski/Branden Taggart Date: 4/27/2017&5/3/2017
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