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Permit (4)
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT / fJ IN Request for Permit Action /a �� /9 thlli q / 1-1 G A R[) 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 E Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: ,j l INVOICE TO: (Business or Individual) ` CLJ L' t\ O C(\e__ V t _ 6CLf T %.Ga, Mailing Address 3 g �/-�1/ O J City/State/Zip: �0 (' r �� 2Z'( Phone No.: S V ', — 9 4_0 - Li to 0 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: / 34 /`1 ,70/ 9 r DD 410 , Site Address or Parcel#: Project Name: Subdivision Name: Lot#: EXPLANATION: J 4fe...r Aid F. /e) -�0✓f i e7, c c_ O/ 7-9-r n J /°EX.'-t i T -- Ln-r E-x- .2 � -. Signature: Date: /C? /24-t / 1 7/ Print Name: ,/� �Z -tea fAi ` l 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. /37. 5e - /io . d 2 7 - Sa- / G , Si / 2 - al - 3 . 3o • .i 7 - 3 d, e',2 FOR OFFICF I SF ONL\ Route to S s Admin: Date , ?s /j` By Route to Records: Date' 3 77 By / Refund Processed: Date//i //,f/9 By, Invoice Processed: Date By Permit Canceled: Date 4) 2c // Q By,01 17 Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_12 518.doc ,tr - a TIGARD City of Tigard November 8, 2019 Hawthorne Villa Apartments 13489 NW Trevino St Portland, OR 97229 Re: Permit No. PLM2019-00402 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 7705 SW Pfaffle St Project Name: Hawthorne Villa Apartments Job No.: N/A Refund Method: ® Check #233839 in the amount of$123.27. ❑ Credit card "return"receipt in the amount of$ 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 job was cancelled. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, 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 r c n Ez D 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 for Permit 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: Hawthorne Villa Apartments DATE: 11/1/2019 13489 NW Trevino St Portland, OR 97229 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 426621 Case#: PLM2019-00402 Date: 10/24/2019 Address/Parcel: 7705 SW Pfaffle St Pay Method: Check Project Name: Hawthorne Villa Apartments EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Plumbing Permit Fees 230-0000-43101 $110.06 12%State Surchage 100-0000-24001 13.21 TOTAL REFUND: $123.27 APPROVALS: SIGNATURE ATE: If under$5,000 Professional Staff (42 If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: 9/1/y./ By: .40 I:\Building\Refunds\RefundRequest.doc x 09/01/2010 w:- CITY OF TIGARDIN RECEIPT ✓r 13125 SW Hall Blvd.,Tigard OR 97223 41 503.639.4171 TIGARD Project Name: Hawthorne Villa Apartments Site Address: 7705 SW PFAFFLE ST 7,,,� y, Receipt Number: 436189 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00402 $-123.27 Total: $-123.27 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 233839 DHOWSE 09/03/2021 $-123.27 Payor: Hawthorne Villa Apartments Total Payments: $-123.27 Balance Due: $123.27 Page 1of1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Hawthorne Villa Apartments Site Address: 7705 SW PFAFFLE ST 40416-1/7e Receipt Number: 426621 - 10/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00402 Water Service 230-0000-43101 $137.58 PLM2019-00402 12% State Surcharge-Plumbing 100-0000-24001 $16.51 PLM2019-00402 Returned Check Fee 230-0000-45151 $20.00 Total: $174.09 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 2392 DHOWSE 10/24/2019 $174.09 Payor: Hawthorne Villa Apartments Total Payments: $174.09 Balance Due: $0.00 Page 1 of 1 Print Images Page 1 of 1 Account Number: ' MICR Acct. #: I ,uting #: 323070380 Check#: 1054 Store#: 0000000000 Type: Return Return Reason: NSF- Not Sufficient Funds Amount: $154.04 Date: 10/10/2019 Sequence#: 1099006267 Front - -.• �... _ "� . .. • ++.r i .. • rMw rr..�.r. r..ra...r. MILEY AND SONS UTILITIES LLC f91 N HOLLY AVE 1054 STAYTON.OR 97713300WO 2$7oaras0e 11111111 Date 10 -y- / Payrof �,t $ .1/ Dollars a BANK OFAMERICAyee.' MN Scormo For feorr4- 77oS farPler ror �•g 4.'r•••.•.-rt v i.r.w 4! . q<.r•.-4 y...gg T�'�...r".ad'g1 � :�M-a.•."Hr•-�w.w4%•wA••�..ir7 f•veeos a.m. Back: � 11111/ /0v0.? ©r s r-i oe2 erg f Q2 v 7v �? Tom /1-tiii,,r i r64064T /O/i s/i https://singlepoint.usbank.com/cs70_banking/sbb/app/smallbiz/image/printImagesFrom V... 10/14/2019 License Professional (Edit) Page 1 of 1 PLM2019-00402-Hawthorne Villa Apartments Menu Submit Reset Cancel Help License Type * License# * First Name Last Name Prima FMB 225686 Business Name Primary Phone llxxx>xxx-xxxx) MILEY AND SONS UTILITIES LLC (971)273-3880 Address Line 1 Phone 2 191 N HOLLY AVE Address Line 2 Fax Address Line 3 City State ZIP Code STAYTON OR 97383 E-mail D`/y/l5 / 'Z0 V/1 w�Et t, Ali( E y — C� . 9-c-re_ r, 7 ,=, .17000 /6/(.5/./ /4-.1 https://ay.accela.com/portlets/professional/professionalEdit.do?value(mode)=edit&value... 10/14/2019 1114 CITY OF TIGARD RECEIPT a . 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Hawthorne Villa Apartments Site Address: 7705 SW PFAFFLE ST Receipt Number: 426621 - 10/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00402 Water Service 230-0000-43101 $137.58 PLM2019-00402 12% State Surcharge-Plumbing 100-0000-24001 $16.51 PLM2019-00402 Returned Check Fee 230-0000-45151 $20.00 Total: $174.09 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 2392 DHOWSE 10/24/2019 $174.09 Payor: Hawthorne Villa Apartments Total Payments: $174.09 Balance Due: $0.00 Page 1 of 1 i III., , CITY OF TIGARD RECEIPT • 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Hawthorne Villa Apartments Site Address: 7705 SW PFAFFLE ST -C �2A Receipt Number: 426620 - 10/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00402 $-154.09 Total: $-154.09 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1054 DHOWSE 10/24/2019 $-154.09 Payor: Miley and Sons Utilities LLC Total Payments: $-154.09 Balance Due: $154.09 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Hawthorne Villa Apartments Site Address: 7705 SW PFAFFLE ST Receipt Number: 426283 - 10/07/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00402 Water Service 230-0000-43101 $137.58 PLM2019-00402 12%State Surcharge-Plumbing 100-0000-24001 $16.51 Total: $154.09 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1054 BTAGGART 10/07/2019 $154.09 Payor: Miley and Sons Utilities LLC Total Payments: $154.09 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD PLUMBING PERMIT ' COMMUNITY DEVELOPMENT71 Permit#: PLM2019 00402 T' ARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/07/2019 Parcel: 1 S136CA01500 Jurisdiction: Tigard Site address: 7705 SW PFAFFLE ST Project: Hawthorne Villa Apartments Subdivision: None Lot: None Project Description: Direction drill 230 ft.of water service main line. Contractor: MILEY AND SONS UTILITIES LLC Owner: HAWTHORNE VILLA APARTMENTS 191 N HOLLY AVE 13489 NW TREVINO ST STAYTON, OR 97383 PORTLAND, OR 97229 PHONE: 971-273-3880 PHONE: FAX: FEES Quantity Description Date Amount 230 If Water Service 10/07/2019 $137.58 Specifics: 1 12%State Surcharge- 10/07/2019 $16.51 Plumbing Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $154.09 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 503.232.19: • .800.332.2344. Issued By: r---------:7' Permittee Signature: x/19 ". 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. Plumbing Permit Application Building Fixtures FOR OFFICE USE ONLY City of Tigard RECEIVE s ate/BPermit No/.,,p/ III13125 SW Hall Blvd.,Tigard,OR 97223 y' ��/� ,a U"/¢ -��( Phone: 503.718.2439 Fax: 503.598.1960 OCT 7 Plan Review 2 019 Date/By: Other Permit No.: T I G A R D Inspection Line: 503.639.4175 Date Y Read/B Juris: El See Page 2 for Ready/By:Internet: www.tigard-or.gov CITY OF -'-IG A RDNotified/Method: /_ Supplemental Information TYPE OF WORKRI lit I'1t�C ftVISION FEE* SCHEDULE ❑New construction ❑Demolition Description For special information use checklist Description I Qty. I Ea. Total Mil ddition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection) CATEGORY OF CONSTRUCTION SFR(1)bath 312.70 X'I-and 2-family dwelling ❑Commercial/industrial SFR(2)bath 437.78 ❑Accessory building 0 Multi-family SFR(3)bath 500.32 ❑Master builderEach additional bath/kitchen 25.02 0 Other: Fire sprinkler( sq.ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: 7 0 J S P�,,fl I Catch basin or area drain 18.76 e.City/State/ZIP: 7c,yri a^ Z Drywell,leach line,or trench drain 18.76 l 9 / I / 1.3Footing drain(no.linear ft.: ) Page 2 Suite/bldg./apt.no.: I Project name: 1,/•-°+�e^ ' gni Manufactured home utilities 50.03 Cross street/directions to job site: 7 q.w 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.:23k,..) 3 Page 2 1 37 571 Subdivision: I Lot no.: Fixture or item: Tax map/parcel no.: Backflow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Jr; lothes washer 25.02 D;re-cd;cre✓] eII n,u) ()dolor Service. I'lOV`A 1:1, Dishwasher 25.02 Drinking fountain 25.02 Ejectors/sump 25.02 ❑ PROPERTY OWNER I 0 TENANT Expansion tank 12.51 Name: Fixture/sewer cap 25.02 Floor drain/floor sink/hub 25.02 Address: Garbage disposal 25.02 City/State/ZIP: Hose bib 25.02 Phone:( ) Fax:( ) Ice maker 12.51 APPLICANT ❑ CONTACT PERSON Interceptor/grease trap 25.02 Business name:1.1:fey. LA) 5„,,,.5 /4.1 t, Medical gas(value:$ ) Page 2 S Primer 12.51 Contact name: gI CIL y Roof drain(commercial) 12.51 Address: 1 el ' Al /4o//y. AX.- Sink/basin/lavatory 25.02 City/State/ZIP: �jGi...r, h! e. 2. Cf ' 3 3 Solar units(potable water) 62.54 Phone:(C/7/ )z 73-��"°3'-'n o Fax::( ) Tub/shower/shower pan 12.51 E-mail: y'i GK ti "1,7 Gw 10 ay'/, C o M Urinal 25.02 O CONTRACTOR Water closet 25.02 Water heater 37.52 Business name: M � S6�� r ' cid;/ r +� S Water piping/DWV 56.29 Address: 9 q/ jv if d 3( Ale Am, Other: 25.02 City/State/ZIP: e.71714107,_) 0y, t 3 Subtotal /37 51 Phone:(61 7/ ) 2,7 3 3 O Fax:( ) Minimum permit fee: $72.50 zz r6 Plan review (25%of permit fee) CCB Lic.: (, Plumbi 'c.no.: State surcharge(12%of permit fee) (t .SJ cf-6, Authorized signature: TOTAL PERMIT FEE /5-y f' Print name: ti ( Date"0 -ty_ /7This 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: Residential Fire Suppression Systems: Site Utilities Qty. Fee(ea) Total Square Footage: Permit Fee: Footing drain-I"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 i✓;(5-1 Medical Gas Systems: Water Service-each additional 100' 6.2 37.52 75:v T Valuation: Permit Fee: 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 Other Inspections or Fees Qty. Fee(ea) Total each additional$100.00 or fraction thereof,to p 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: /3 7 Si 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*. Plan Review for Plumbing Installations Quantity by Fixture Type Plan review is required for any of the following. Fixture Type for Replace/ Please check all that apply. Work Performed: Capped Added Relocate ❑ Any new commercial building with water service 2"and Baptistry/Font greater,except systems designed and stamped by licensed Bath: -Tub/Shower engineer. -Jacuzzi/Whirlpool Car Wash: -Each Stall 0 New exterior plumbing site utilities for any complex structure as defined in OAR918-780-0040. -Drive Thru Cuspidor/Water Aspirator ❑ Medical gas and vacuum systems for health care facilities. wash : -Commercial al 0 Any multipurpose fire sprinkler system. sh Domestic ❑ Any complex structure as defined in OAR918-780-0040. Drinking Fountain Eye Wash Submit 2 sets of plans with any of the above. Floor Drain/sink: -2" 3" Isometric or Riser Diagram 4" 0 Isometric or riser diagram is required for new buildings -Car Wash Drain that meet the qualifications above. Garbage -Domestic non-food Disposal: -Domestic food related -Commercial food related -Industrial food related Ice Mach./Refrig.Drains Comments regarding fixture work: Oil Separator(Gas Station) Rec.Vehicle Dump Station Shower: -Gang -Stall Sink: -Lav/Bar non-food related -Bradley -Com/Serv/Util food related -Service *Note: If the fixture work under this permit results in an Swimming Pool Filter increase of sewer EDUs,a sewer permit will be issued and Washer-Clothes fees assessed for the sewer increase must be paid before the Water Extractor Water Closet-Toilet plumbing permit can be issued. Urinal Other Fixtures: I:\Building\Permits\PLMF_PermitApp.doc 08/04/2011 2