Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ DO
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Request for Permit Action oX ?/
T I C A R U 13125 SW Hall Blvd. • Tigard, Oregon 97223 . 503-718-2439 • www.tigard-or.gov '�a
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 ❑ Applicant X❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Steele Electric
Mailing Address: 7741 SW Cirrus Dr
City/State/Zip: Beaverton, Or 97008
Phone No.: 503-268-1311
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 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#: ELC2021-00434
Site Address or Parcel#: 11250 SW 78th Ave,Tigard 97223
Project Name:
Subdivision Name: Lot #:
EXPLANATION: This project was not completed. Customer decided to wait
Signature: 0..14itan. Date: 08/27/2021
Print Name: Kandice Whitten
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. /5-6, cp."- _ /?5 Sa .37 3
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date '? 'f Aral B /
Refund Processed: Date d7a7/3-/ By Invoice Processed: Date By
Permit Canceled: Date 1/,,).7 By (9 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518. ofl c
1111
TIGARD
City of Tigard
September 2, 2021
Steele Electric
7741 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELC2021-00434
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11250 SW 786'Ave
Project Name: AS6529
Job No.: N/A
Refund Method: ® Check#240446 in the amount of$140.56.
❑ Credit card "return"receipt in the amount of$
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,
ekee)//ryte_Zer...0---
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
Il City of Tigard
r i c n 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: Steele Electric DATE: 8/27/2021
7741 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 435704 Case#: ELC2021-00434
Date: 8/5/2021 Address/Parcel: 11250 SW 78th Ave
Pay Method: CreditCard Project Name: AS6529
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permt fees.
REFUND INFORMATION:
Fee Description From Receipt ' Revenue Account No. ' Refund
Example: Building Permit Fee Example: 2300000-43104; ,$;;Amount.,,
Permit Fee 220-0000-43103 $125.50
12%State Surcharge 100-0000-24001 15.06
TOTAL REFUND: $140.56
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff If under$12,500 Division Manager0/Za�---
)
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: 1 Date: J`{-,/ r Bv:, •4'1;
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
r 13125 SW Hall Blvd.,Tigard OR 97223
f� 503.639.4171
'TIGARD
Project Name: AS6529
Site Address: 11250 SW 78TH AVE 4r
Receipt Number: 436286 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00434 $-140.56
Total: $-140.56
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240446 DHOWSE 09/04/2021 $-140.56
Payor: Steele Electric
Total Payments: $-140.56
Balance Due: $140.56
Page 1 of 1
CITY OF TIGARD RECEIPT
E. 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: AS6529
Site Address: 11250 SW 78TH AVE U 416 f N'e-L„-
Receipt Number: 435704 - 08/05/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00434 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2021-00434 Branch Circuits wo/Purchase Service or 220-0000-43103 $56.18
Feeder
ELC2021-00434 12% State Surcharge-Electrical 100-0000-24001 $18.83
Total: $175.71
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 8095121 PUBLICUSER109 08/05/2021 $175.71
Payor:
Total Payments: $175.71
Balance Due: $0.00
Page 1 of 1