Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
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, s 'I
III Request for Permit Action '/ . '/'' o
TiTj(;ARD 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 0 Applicant 0 Contractor 0 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) E x-. Dok.x1 ti7
Mailing Address: 3116 N W Pae.; ",S. •
City/State/Zip: L =.-a•e.otr.r•1 C..z-t-f,02 9'43Co-4
Phone No.: 503- 32,9 -Col"-
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE(attach cast; fen scheciul .:tnd provide explanation below).
Permit#: 11 E C.2b 26 — bC.3 59`i
Site Address or Parcel#: 12c47 50 5 F's a.=a e 'Si' .."""ri60,Ca'> eft.ci-422.'3
Project Name: , _
Subdivision Name: Lot#:
EXPLANATION: - t d IS a 1=ch,s- T. I-% F36 E.r—a N .-'c LTTG-4 23ECtat)sC.
T31E Sa +At—k.- sn)As CA►taGc.u."6zl. 8EciN.vsC 0V A ,Claec'1)0. L -...G
A-►> Fs.J iat..CS W t =.ssu E.
Signature: c..>•-$-.,C, . . Date: ►o'%O\202 O
Print Name: ECL->r C. S �50. J
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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(1/0 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. _ lIf,r O z)
' to-a .f' ,ir, . 6 ' . ....9-o , ( c„
FOR OFFICE USE ONLY
Route to Sys Admin: _ Date By Route to Records: Date 9 !1r y- By ,
Refund Processed: Date J„s?/2 By e' Invoice Processed: Date By
Permit Canceled: Date �,7 .a./ By d Parcel TagAdded: _Date By
I:\Building\Forms\RegPermitAction_120518.doc
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"
TIGARD
City of Tigard
September 2, 2021
Eric Dodson
3116 NW Port Ave
Lincoln City, OR 97367
Re: Permit No. MEC2020-00599
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12650 SW Katherine St
Project Name: Dodson
Job No.: N/A
Refund Method: ® Check#240408 in the amount of$80.64.
❑ Credit card"return"receipt in the amount of$
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 Ornelas
Building Division Services Supervisor
Enc.
� I'I
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
11111
City of Tigard
T I G A R 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: Eric Dodson DATE: 8/27/2021
3116 NW Port Ave
Lincoln City, OR 97367 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 430998 Case#: MEC2020-00599
Date: 9/12/2020 Address/Parcel: 12650 SW Katherine St
Pay Method: CreditCard Project Name: Dodson
EXPLANATION: Per applicant's reuqest 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
Permit Fee 230-0000-43102 $72.00
12%State Surchage 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff -)
If under$12,500 Division Manager .1.� 44--- e.": ��
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: %`, 6:r ye t;✓ By: ' °
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
711 CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T 14.;A tx..:D
Project Name: Dodson
Site Address: 12650 SW KATHERINE ST
Receipt Number: 436279 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M EC2020-00599 $-80.64
Total: $-80.64
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240408 DHOWSE 09/04/2021 $-80.64
Payor: Eric Dodson
Total Payments: $-80.64
Balance Due: $80.64
Page 1 of 1
CITY OF TIGARD RECEIPT
N 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
T t C A IR.D
Project Name: Dodson
Site Address: 12650 SW KATHERINE ST a,(6- /A7
Receipt Number: 430998 - 09/12/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2020-00599 Wood Fireplace/Insert 230-0000-43102 $23.32
MEC2020-00599 12% State Surcharge-Mechanical 100-0000-24001 $10.80
MEC2020-00599 Minimum Fee Adjustment-Mechanical 230-0000-43102 $66.68
Total: $100.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6796541 PUBLICUSERO 09/12/2020 $100.80
Payor:
Total Payments: $100.80
Balance Due: $0.00
Page 1 of 1
Dianna Ornelas
From: #Building Permit Technicians
Sent: Tuesday,July 13, 2021 11:10 AM
To: Eric Dodson
Subject: RE: Request for Permit Action MEC2020-00599
Hello Eric,
Unfortunately this refund has not yet been processed as we continue to work through the backlog of refund requests
during COVID remote working conditions.
It is in the que for processing, and it should be completed within the next month and we plan to reopen August 9th
We sincerely apologize for any inconvenience and thank you for your patience!
Dianna L. Ornelas
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
From: Eric Dodson <erjdodson@gmail.com>
Sent:Tuesday,July 13, 2021 2:11 AM
To:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov>
Cc: Dianna Ornelas<Dianna@tigard-or.gov>
Subject: Re: Request for Permit Action MEC2020-00599
Caution!This message was sent from outside your organization.
Hello and Greetings from Ghana!
Can you confirm that a refund check was sent out for the request noted here. It has never been received by my parents.
I would have assumed it would have been processed and mailed by now.
Thank you and best regards,
Eric Dodson
Sent from my iPad
On Mar 17, 2021, at 2:13 PM, Eric Dodson <eridodson@gmail.com>wrote:
Please find below the completed request with explanation.
Regards,
1
Eric
<image0.jpeg>
Sent from my iPad
On Mar 9, 2021, at 3:57 PM, #Building Permit Technicians
<TigardBuildingPermits@tigard-or.gov>wrote:
Eric,
We will need you to complete the explanation section of the form before we can
process your request for a refund. Please resend the form once it is complete.
Thank you,
<image001.jpg>
From: Eric Dodson <erjdodson@gmail.com>
Sent:Tuesday, March 9, 2021 7:50 AM
To:#Building Permit Technicians<TigardBuildingPermits@tigard-or.gov>
Cc: Eric Dodson <dodsons4ghana(ddgmail.com>
Subject: Fwd: Request for Permit Action MEC2020-00599
Please receive and complete the attached request form.
Regards,
Eric Dodson
Sent from my iPad
Begin forwarded message:
From: Eric Dodson <eridodson@gmail.com>
Date: March 9, 2021 at 3:37:07 PM GMT
Cc: Eric Dodson <dodsons4ghana@gmail.com>
Subject: Request for Permit Action MEC2020-00599
Please find the above form subject, below.
I sent it back in October, but was advised it was never received. Please
process ASAP.
Regards,
Eric Dodson
2
Sent from my iPad
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public
record laws. If requested, e-mail may be disclosed to another party unless exempt from
disclosure under Oregon Public Records Law. E-mails are retained by the City of Tigard
in compliance with the Oregon Administrative Rules"City General Records Retention
Schedule."
<Ca mScanner 10-13-2020 12.46.44.pdf>
3
CITY OF TIGARD MECHANICAL PERMIT
COMMUNITY DEVELOPMENT111
Permit#: MEC2020-00599
Date Issued: 9/21/2020
'TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S104AA08500
Jurisdiction: Tigard
Site address: 12650 SW KATHERINE ST
Project: Dodson Subdivision: BELLWOOD NO.2 Lot: 100
Project Description: Install wood fireplace insert with stainless steel liner.
Contractor: OWNER Owner: DODSON, ERIC J &KATIE L
3116 NW PORT AVE
LINCOLN CITY, OR 97367
PHONE: PHONE:
FAX:
FEES
Specifics: Description Date Amount
Wood Fireplace/Insert 09/12/2020 $23.32
Type of Use: SF 12%State Surcharge-Mechanical 09/12/2020 $10.80
Class of Work: ALT Type of Const: Minimum Fee Adjustment-Mechanical 09/12/2020 $66.68
Occupancy Grp:
Stories:
Fuel
Fuel Types:
Gas Pressure:
Total $100.80
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 50 . 2.1987 or 1.800.332.2344.
Issued By: Permittee Signature: lki IV/WC "LM/
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
Th' permit card shall be kept in a conspicuous place on the Job site until completion of the project.
Approved plans are required on the Job site at the time of each inspection.
..ha weal Permit Applicationm
11)1?(}1 i I( I:I SI tiN1.1
City of Tigard Received , i /
1112i„4W11.ill Illvd.,Tiganl,OR 97223 Dalear (:///// 2-1'; 4)Cl ramaN2c 2c CO 5Cifi
e
„ Phone' 5111.718.2439 fax: 503.598.1960 PbnRview er Da pp,\I,ill Inspection Line: 501639A 175 OthRemit:tear
Internet. www.Ilhard-rw.gm 114'ItemiilaT c-.7 , A JUnK I Ei.Seg Page 2 far
N9fificd/Niethod:/ i I 2.0 AY 0 I Shoolethertsi lefermatiou
..: TYPE OF WORK :cOssuRRCIAFFRIF",SCIIEDITLE;;.-.'USE 0IPOMIST
C3 New ctmstruction 0 Addition/alteration/replacement performed.MechanitallacticarePanlii frestlic.vawluer bash:ind°nedthtoe thvaletienearestorthedl/ar.°4)°fall 0 Dernoliti ttri %Other: mechanical materials,equipment,labor,overhead.and profit
••,-._______
Value:$ 3,LI 90
CATEGORY OP.•corisrumcnott'r.,:;„,::='-z- a . ,..s.,..4.,.............
tf I-and r ' dwelling ------.°--*------
2-[may 0 Commercial/industrial 0 Accessory building For special information;me checklist.0?OM ti-family 0 Master builder 0 Other Description Qty. Ea. Total
,
JOB RITE INFORMATIO4N AND LOCATION
Air conditioning 46.75
' I
Jols site address: 1'2 SO 'Sxesa 14 Furnace 100,000 BTU(duets/venni 46.75
-. .,.. ,,,,.....
'TT Cpsial2 0,ifS‘ gl-4 2.2'"
Suite/bldg./apt.no.: 1 Project name: Heat pump 61.06
Dud work , 2332
Cross strect/directiona to job site: Hydronic hot waxer system 23.32
Residential boiler(radiator or
hydroniel 2332
Unit heaters Cruel-type,not eteetriet
• .. • . , . . ..,.„
Flue/vent for any of above 2332
Subdivision: Lot no.: Other 23.32
Other fuel appliances:
Tax Map/parcel no.: Water heater 23.32
33.39 DESCRIPTION OF WORK''..",..:_-. =-.'-:, ,,!,1,-;‘..,..1';':-.-'27---L-------, -, Gas fircyllacernr.er'
Flue von for water heater or am
liatrrAt•Le NIM moo, Cr=t2.E.Px•pix.c.E. =•••••Stift-r spa. -r‘A • •••.-A:=. .‘...e.v.s. tlIWIletli...:
Log lighter(gas) 23.32
r-scsZ. ,
Wood/pellet stove 3339
Wood fireplacc/inscrt I 23.32
Chimney/liner/lludvent 2332
Other 2332
- ITXPIIDF;RRTV-OWNFR--,-,••--••-,-•1 '-.."41:,,,,....,_,....,,,ri•...71ZNATIT--..,.4,....i.....,..7"...........
Range hood/other kitchen
Name:
equiPmeal 3339
i Clothes dryer exhaust 33.39 Address: i'2(o5C3 "S•r•-• K 0.-s-o.c.-sz. e.oe. 5-, •
Single-duct exhaust(bathrooms,
City/Slate/ZIP: -r-c4,0„cz. ‘,012_ C‘,"Z 22-3
toilet compartments,utility roonts) 2332
Phone:(503) S Fax:( ) Atiickrawlspace fans 23.32
(.."9 -)$‘10
-.3)(etrrk.sulie•s '--,,-,--,-,^1---"-I''-'1"""*"'""LI'••••tn'y 4/11:t•iIPTr",-,u01--rirM-1 Fuel;Iping:
Busines name: $14.15 for first tour;$4.03 for each additional
s
Furnace,etc.
Contact name: e-.",,..s_c_ .1.- 117 ,50.,_
Gas heat pump
Addres-t: t-2.Co 50'' '‘c's•N 14.c..n.-.-Vett--i r-J SS i •
Walllsuspendedhmit heater
...
...._.--,1.• -rsr,pa...h> icsa et-4,2_2:5
Fireplace
-
Fax::( ) '
',bone:(503) toci 1 at LP Range
L A cr... .,,,,-., N,.....0.;%.c..01-A. Barbecu
r;_mai I: e r• slIP'• e
CONTRACTOR ,.-,.':. ,-__:_, "-::!'. z:?,:,:-..;T: ,.--•.E., 1'12.',::., Clothes dryer(gas)
— .
Chher:
' - "„11.4Crn 4NtrA1 AVIARY'fiVrtA
iiLLNinCS__:....%r___IarTICte 0,4")
Subt0i21 2.3_32
---
Addm'a:
Minimum permit fee(S90.00)
, trityiStatertIF:
Plan review(25%of pamit fee)
Fax:( ) State surcharge(trh of permit fee) 1 V
pimyrit:( )
TOTAL PERMIT FEE (ert) , g'()
..-------_
cos lie,:
This permit aPPlicatIon expires if a permit Is not obtained within 180
n
ilootred siga •
llre: Cl....1P-C-',. f •
Fee methodology set by Tri-County Building industry Service Board
Au _
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