Permit Support Document VOIrJ
Nr City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /�//-S/ZD ��
I Request uest for Permit Action
TIGARD 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 ❑ Applicant ❑ Contractor ! ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Q /2./( ,,kJ f �L��7 � tu'6
Mailing Address: 30 5' -s 3 (--- u Er-
City/State/Zip: C- T I/-47`-t , 7cF6
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Pfc CANCEL/VOID PERMIT APPLICATION.
r REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
1111 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: el-C 2-0 2) 60 (a 17
Site Address or Parcel#: 2'6 Ft) fir) ! v� ' 0 et)ls G AJ
Project Name:
Subdivision Name: Lot #:
EXPLANATION: W O f2-K /' 4-.Fp4.w(,Gt Go 20 493.E 3
try e?,) P t r l r° ' -r S
Signature: ef94, � Date: `,)-€9
Print Name: /4--A/AAet---
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. /�O •O
�9.
• l7
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date / Y 2..e. By
Refund Processed: Date,g,/,97/a/ By Invoice Processed: Date By
Permit Canceled: Date../ 58/ () By 4,.)
0 Parcel Tag Added: Date By
I:\Building\Forms\Reg P ermitAc lion_1 051 .doc
q
TIGARD
City of Tigard
September 2, 2021
Orient Electric Inc.
30532 SE Bluff Rd
Gresham, OR 97080
Re: Permit No. ELC2020-00617
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9680 SW Riverwood Ln
Project Name: McHugh
Job No.: N/A
Refund Method: ® Check#240432 in the amount of$179.27.
❑ Credit card "return"receipt in the amount of$
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): Work performed under master permit MST2020-00323. Refund 100%
of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
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
1 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: Orient Electric Inc. DATE: 8/27/2021
30532 SE Bluff Rd
Gresham, OR 97080 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 432090 Case#: ELC2020-00617
Date: 12/9/2020 Address/Parcel: 9680 SW Riverwood Ln
Pay Method: CreditCard Project Name: McHugh
EXPLANATION: Work performed under master permit MST2020-00323. Refund 100%of permit fees
paid.
RE1 D INFO IATION:
Fee Description From Receipt Revenue Account No. d�Example: Building Permit Fee Example:;2300000-43104 $Amount :,
Permit Fee 220-0000-43103 $160.06
12%State Surchage 100-0000-24001 19.21
TOTAL REFUND: $179.27
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager p0bl7A/1°,4-4.---
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: y/41/�j By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
'TIGARD
( A� 503.639.4171
6 I�G A R D
Project Name: Above Garage
Site Address: 9680 SW RIVERWOOD LN
Receipt Number: 436283 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00617 $-179.27
Total: $-179.27
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240432 DHOWSE 09/04/2021 $-179.27
Payor: Orient Electric Inc.
Total Payments: $-179.27
Balance Due: $179.27
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T fGAIfiD
Project Name: Above Garage
Site Address: 9680 SW RIVERWOOD LN )ki‘ �!
Receipt Number: 432090 - 12/09/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00617 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2020-00617 Branch Circuits w/Purchase Service or 220-0000-43103 $59.36
Feeder
ELC2020-00617 12%State Surcharge-Electrical 100-0000-24001 $19.21
Total: $179.27
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7121724 PUBLICUSER148 12/09/2020 $179.27
Payor:
Total Payments: $179.27
Balance Due: $0.00
Page 1 of 1