Permit Support Document (2) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
to
Request for Permit Action
i ,:. ,,„,, 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • ,..W W_u;.,q_dw_0 r .i%
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fair 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ® Contractor ❑ City Staff
check of)one
REFUND OR Name:
INVOICE TO: (Butioesror'ndivid"a9 Nice Electric Co
Mailing Address: PO Box 636
City/State/Zip: McMinnville OR 97128-0636
Phone No.: 503.434.5802 h aJ ,i i' .e.. CC wt.
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(/):
CANCEL/VOID PERMIT APPLICATION.
41/2 REFUND"PERMIT FEES(attach copy of original receipt and provide explanation below).
• 'y4 • II ••ICE FOR FEES DUE(attach case fee schedule and provide explanation below).
Permit#: ELC2021-00191
Site Address or Parcel#: 11230 SW Buffalo Pl
Project Name: Pure Environmental
Subdivision Name: Dakota Meadows Lot#: 8
EXPLANATION:
_
This is a burn job. However,I did not
-know that the first floor was not damaged,so the
service was not affected. Pleas DELETE the Service,but add FOUR(4)more Circuits
for the upstairs remodel.T t i es us a total of FOURTEEN 04)Circuits&No Service.
Signature: Date: 5/3/2021
Print Name: Jennifer J Sio ks,Office Manager
Ref ndPolicy
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• Not more than 80%of the application or plan review fee when en application is withdrawn or canceled before review effort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. t 9 C. 1
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Route to ays.Adman: Dare By Route to Records: Date 9 N ' 1 B.
Refund Processed: Date V,-/ By'I� Invoice Processed: Date / " _k
Permit Canceled: DateB ) , Parcel Tag Added: Date By''\lltn3digg\Fcam3\Regt'emrtAction
IIIa
TIGARD
City of Tigard
September 2, 2021
Nice Electric Co.
PO Box 636
McMinnville, OR 97128-0636
Re:Permit No. ELC2021-00191
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 11230 SW Buffalo P1
Project Name: Pure Environmental
Job No.:
Refund: ® Check#240428 in the amount of$24.93.
❑ Credit card"return"receipt in the amount of$ .
❑ Trust account"deposit"receipt in the amount of$ .
Notes: Per applicant's request as a change in scope of work resulted in overpayment of
permit fees and refund of the difference.
If you have any questions please contact me at 503.718.2430.
Sincerely,
e<a,5 :(a,/,,,..__e_/‹...4___./
Dianna Ornelas
Building Division Services Coordinator
Enc.
I:\Boilding\Refunds,i iiia Aiiiikiiidzdvela a iWregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
1Cit111
y 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: Nice Electric Co DATE: 8/27/2021
PO Box 636
McMinnville, OR 97128-0636 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 433808 Case#: ELC2021-00191
Date: 4/13/2021 Address/Parcel: 11230 SW Buffalo P1
Pay Method: CreditCard Project Name: Pure Environmental
EXPLANATION: Per applicant's request as change in scope of work resulted in an overpayment of permit
fees;refund 100%of difference.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee,_..r.e Exmple: 2300000-43104 $Amount
Cash Over 100-0000-48001 $24.93
TOTAL REFUND: $24.93
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager ,��►i1___/
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: � '�� `' i•-• By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
U
CITY OF TIGARD RECEIPT
g 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Pure Environmental-11230 Buffalo
Site Address: 11230 SW BUFFALO PL AC A//
Receipt Number: 436285 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00191 $-24.93
Total: $-24.93
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240428 DHOWSE 09/04/2021 $-24.93
Payor: Nice Electric Co.
Total Payments: $-24.93
Balance Due: $24.93
Page 1 of 1
1111 CITY OF TIGARD RECEIPT
2 . 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Pure Environmental-11230 Buffalo
Site Address: 11230 SW BUFFALO PL
Receipt Number: 433808 - 04/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00191 Branch Circuits wo/Purchase Service or 220-0000-43103 $152.64
Feeder
ELC2021-00191 12% State Surcharge-Electrical 100-0000-24001 $18.32
ELC2021-00191 Cash Over 100-0000-48001 $24.93
Total: $195.89
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7609311 PUBLICUSER126 04/13/2021 $195.89
Payor:
Total Payments: $195.89
Balance Due: $0.00
Page 1 of 1