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Permit Support Document (37) 0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 , . " II Request for Permit Action i./6/fes T I C;A R I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov I'V - TO: CITY OF TIGARD *" u Building Division OCT i 1 2018 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax 503-598-1960 TigardBuildingPermits@tigard p g y FROM: ❑ Owner ❑ Applicant ❑ Contractor IN. City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. 11) S` REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). /IV' G ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: PL-A4 A 01 8--001?, (X rS Site Address or Parcel#: /7o L-1�3- s'� Air /r/r 47t 1 d /t' Project Name: Rive-,r /Tee r . G 7.497.3- - t/�!!2� C Subdivision Name: / Lot #: EXPLANATION: ' nie4,"7-- is 0,1 7.v2fcr/ / il/i 7`.. rr,/' # <s A- 'i ,G✓ 72, 'cuw/ice .i1. .Z v T atm A..,-/: letes r eYr�7`z a �•r / ignature: ?'0��� Date: Print Name: u,,/I•.r /Ot 6 fr1 f i .- /' elk!•r4 42 I /7.; Refund Policy Ca-/ttvl,0/8-OO lc rJ) 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: eel'? el D • 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 tt ,f By ti' Route to Records: Dat- ! /1.--- iair' 'V l e€nit Processed: Date/Vic,- /d By err Invoice Processed: Date By Permit Canceled: Date Mite"' By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_(f923 4.doc CITY OF TIGARD PLUMBING PERMIT 11 COMMUNITY DEVELOPMENT Permit#: PLM2018-00476 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/11/2018 T[c;A ix C3 g Parcel: 2S1060001400 Jurisdiction: Tigard Site address: 17043 SW APPLEDALE RD Project: River Terrace East Apartments,Building C Subdivision: RIVER TERRACE EAST Lot: None Project Description: Building C: New 12 unit apartment building. Backflow preventer for landscape irrigation. Contractor: ANDERSEN HEATING, INC. Owner: POLYGON WLH, LLC 16285 SW 85TH AVE STE 410 703 BROADWAY ST, SUITE 510 TIGARD, OR 97224 VANCOUVER,WA 98660 PHONE: 360-695-7700 PHONE: 503-992-6664 FAX: 503-536-6615 FEES Quantity Description Date Amount 1 ea Backflow Preventer 10/11/2018 $31.27 Specifics: 1 12%State Surcharge- 10/11/2018 $8.70 Plumbing Type of Use: SF 41 ea Minimum Fee Adjustment- 10/11/2018 $41.23 Plumbing Class of Work: OTR Type of Const: Occupancy Grp: Stories: Total $81.20 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: /1 �� I Permittee Signature: �� Gc- • 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. General Ledger Journal Entry Proof List 1111 User: amyl V Printed: 11/20/2018- 5:14 PM ' Batch: 10007.11.2018 TIGARD Account Number Account Description Debit Amount Credit Amount Line Description Project Management Journal Entry:312-05-2019 Journal Entry Date:11/20/2018 100-0000-24001 State Building Permit Surcharg 8.70 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00476 100-0000-22000 Customer Deposits 0.00 72.50 Correct Polygon Permit Duplicates-Case PLM2018-00476 100-0000-22000 Customer Deposits 0.00 8.70 Correct Polygon Permit Duplicates-Case PLM2018-00476 100-0000-24001 State Building Permit Surcharg 8.70 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00475 100-0000-22000 Customer Deposits 0.00 72.50 Correct Polygon Permit Duplicates-Case PLM2018-00475 100-0000-22000 Customer Deposits 0.00 8.70 Correct Polygon Permit Duplicates-Case PLM2018-00475 100-0000-10100 Cash 145.00 0.00 Fund balance entry for fund 100 230-0000-43101 Plumbing Permits 72.50 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00476 230-0000-43101 Plumbing Permits 72.50 0.00 Correct Polygon Permit Duplicates-Case PLM2018-00475 230-0000-10100 Cash 0.00 145.00 Fund balance entry for fund 230 Journal Entry Totals 307.40 307.40 Journal Entry Balance 0.00 Report Totals: 307.40 307.40 0.00 GL-Journal Entry Proof List(11/20/2018- 5:14 PM) Page 1 a CITY OF TIGARD " = 13125 SW Hall Blvd.,Tigard OR 97223 TIGARD 503-718-2439 TRUST ACCOUNT DEPOSIT RECEIPT Receipt No.: 420555 Date: 12/3/2018 TRUST ACCOUNT ID ACCOUNT CODE AMOUNT 2016-00002 100-0000-22000 $81.20 PAYMENT METHOD CHECK# CASHIER ID Journal Entry JE 312-05-2019 D HOWSE PAYOR: Polygon WLH, LLC COMMENTS: Deposit to trust account. CITY OF TIGARDIII RECEIPT 2} 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T t cv A,R D Project Name: River Terrace East Apartments, Building C Site Address: 17043 SW APPLEDALE RD Receipt Number: 419904 - 10/11/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2018-00476 Backflow Preventer 230-0000-43101 $31.27 PLM2018-00476 12% State Surcharge-Plumbing 100-0000-24001 $8.70 PLM2018-00476 Minimum Fee Adjustment-Plumbing 230-0000-43101 $41.23 Total: $81.20 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Trust Account 2016-00002 JDRINKWATER 10/11/2018 $81.20 Payor: Polygon WLH, LLC Total Payments: $81.20 Balance Due: $0.00 Page 1 of 1