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Permit Support Document VOID ill City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0P/�7/2, Request for Permit Action RECEIVED TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tiil axd or. TO: CITY OF TIGARD CITY OF TIGARD BUILDING � Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant 'J Contractor ❑ City Staff Check(/)one REFUND OR Name: ( Y- - �INVOICE TO: (Business orIndividual) e tlfe — �i C, Le ve // / Mailing Address: / ' '/6/ Se ,i 9 v e. City/State/Zip: Gtat /G 1'h ©/2 "/ 706 Z. Phone No.: _S-p3 — ') 2_ "/ V Z f PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. 2 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach, case fee schedule and provide explanation below).�-,r�Permit#: , . . c--2.02_C,% --O . 6 Site Address or Parcel#: „Sc /41-5'.4 A..'O Project Name: /1117 le- 7r t 6 Subdivision Name: Lot#: EXPLANATION: 'o c_ i c:-d Signature: Date: — tf- 2 Print Name: lcc�1 �iv� rc� 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. yam— s /."--.s9 FOR OFFICE USE ONLY Route to Sys Admin: Date J J-/ By ,, , Route to Records: Date y 1-f By .47 Refund Processed: Date '/ 7�,}/ By /id Invoice Processed: Date By Permit Canceled: Date /��7/.1 f By O Parcel Tag Added: Date By I:\Building\Forms\RcgPermitAction_12 518.doc 111 a TIGARD City of Tigard September 2,2021 Conduit Electric 19461 SW 89th Ave Tualatin, OR 97062 Re: Permit No. ELC2020-00666 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 7490 SW Ashford St Project Name: Hot tub Job No.: N/A Refund Method: ® Check#240405 in the amount of$50.33. ❑ Credit card"return"receipt in the amount of$ 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. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov 11 RI City of Tigard l t cA R►, Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts,documentation and the RequestforPermitAction 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: Conduit Electric DATE: 8/27/2021 19461 SW 89th Ave Tualatin, OR 97062 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 432345 Case#: ELC2020-00666 Date: 12/31/2020 Address/Parcel: 7490 SW Ashford St Pay Method: CreditCard Project Name: A-Z Wire Hui" T.k 13 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 ,x4rrp1, 23 ?000-43104 $Amount Permit Fee 220-0000-43103 $44.94 12%State Surchage 100-0000-24001 5.39 TOTAL REFUND: $50.33 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff yTh 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 9. °, Case Refund Processed: Date: y 7%y By: ./r/ I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Hot Tub Site Address: 7490 SW ASHFORD ST Receipt Number: 436282 - 09/04/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2020-00666 $-50.33 Total: $-50.33 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 240405 DHOWSE 09/04/2021 $-50.33 Payor: Conduit Electric Total Payments: $-50.33 Balance Due: $50.33 Page 1 of 1 CITY OF TIGARD RECEIPT III ` t 13125 SW Hall Blvd.,Tigard OR 97223 -_ '' 503.639.4171 T(r;Ai D Project Name: Hot Tub 0 / Site Address: 7490 SW ASHFORD ST At �'/1i -- Receipt Number: 432345 - 12/31/2020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2020-00666 Branch Circuits wo/Purchase Service or 220-0000-43103 $56.18 Feeder ELC2020-00666 12%State Surcharge-Electrical 100-0000-24001 $6.74 Total: $2 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 7190628 PUBLICUSER10757(12/31/2020 $62.92 Payor: conduit Total Payments: $62.92 Balance Due: $0.00 Page 1 of 1