Permit Support Document DCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ECE1VE
_1! s. Request for Permit Action DEC 3 0 2020
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigar r.gF TIGARD
OUILDINO DIV1GION
TO: CITY OF TIGARD
V I n:____I
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 f 94)-/ 470
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Q Contractor ❑ City Staff
Check(V)one
REFUND OR Name:
(Business or Individual
INVOICE TO: Elite Electric
Mailing Address: PO Box 6313
City/State/Zip: Bend, OR 97708
Phone No.: 541 . 330 . 9750
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ - CANCEL/VOID PERMIT APPLICATION.
❑x 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#: ELC2020-00581
Site Address or Parcel#: 11117 SW Greenburg Rd
Project Name: Greenburg A-Z Wire
Subdivision Name: Lot#:
EXPLANATION: Project was cancelled.
%wwroMwoSignature: Date: 12/30/20
Print Name: Kim Matteson
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. ��
, g, Zte — 7% 6,2
I/ , / ! — p, 9f .2- '2 V ..
%Dq, �7 7 mod. 9 0
Route to Sys Admin: Date /' 36 )-0 By/ r' Route to Records: Date 9 if 2/ By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc
1111 q
.
TIGARD
City of Tigard
September 2, 2021
Elite Electric
PO Box 6313
Bend, OR 97708
Re: Permit No. ELC2020-00581
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11117 SW Greenburg Rd
Project Name: A-Z Wire
Job No.: N/A
Refund Method: ® Check#240409 in the amount of$83.57.
❑ Credit card"return" receipt in the amount of$ .
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,
d,t'( ems'
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
, C City of Tigard
T I t; D Accela Refund Request
AR
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: Elite Electric DATE: 8/27/2021
PO Box 6313
Bend, OR 97708 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 431852 Case#: ELC2020-00581
Date: 11/19/2020 Address/Parcel: 11117 SW Greenburg Rd
Pay Method: CreditCard Project Name: A-Z Wire
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 220-0000-43103 $74.62
12%State Surchage 100-0000-24001 8.95
TOTAL REFUND: $83.57
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager KX5 C /P �Q, —)
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: ,z_f ° '_ By:_ ,ALZ__
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: A-Z Wire RCC20-157
Site Address: 11117 SW GREENBURG RD j'
Receipt Number: 436281 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00581 $-83.57
Total: $-83.57
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240409 DHOWSE 09/04/2021 $-83.57
Payor: Elite Electric
Total Payments: $-83.57
Balance Due: $83.57
Page 1 of 1
CITY OF TIGARD1111 RECEIPT
i : 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Greenburg-A-Z Wire RCC20-157
Site Address: 11117 SW GREENBURG RD idfl.- t /4/ i-z
Receipt Number: 431852 - 11/19/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00581 Branch Circuits wo/Purchase Service or 220-0000-43103 $93.28
Feeder
ELC2020-00581 12% State Surcharge-Electrical 100-0000-24001 $11.19
Total: $104.47
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7054186 PUBLICUSER252 11/19/2020 $104.47
Payor:
Total Payments: $104.47
Balance Due: $0.00
Page 1 of 1