Permit Support Document g City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 Irip
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Request for Permit Action ,A7/2' ' `�
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 TigardBuildingPerrnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor 0 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 1- ( bse'(4c1�..�J l-- Heat and Ala.
Mailing Address: 32City/State/Zip: C,Orn t C,US , or • 911 13
Phone No.: 503- 35°7- 6,273
PLEA TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee/� schedule and provide explanation below).
Permit#: ��IC.�I.i 202J - 00' Vi
Site Address or Parcel#: 01 II SW oak- Sf •
Project Name: go T )
Subdivision Name: y�� y�,�Lot#:
EXPLANATION: bt t) fJO un a wi- ` ' TOb —
3/iSignature: Date: //
Print Name: De 1 C�FXA 1"',n
Fefund_Policy
1. The city's Cyr munity Development Director,Building Official or City Engineer may authorize the refund of:
• Any fwhich was erroneously paid or collected.
• Not more than 80%of the application or plan review fcc when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80°/n 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. q ry/',
/�t �-Z " 61r iS = - `" ` may_
ter. r � � r
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wiz 0 FFiC1; ONLY
Route to Sys Admin: Date By Route to Records: Date - 'f el By 4/
Refund Processed: Date I' >7/?f By,.O e Invoice Processed: Date By
Permit Canceled: Date - :• Parcel Tag Added: Date By
I:\Building\Forms\ReVermitAction_120518.doc
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IN
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TIGARD
City of Tigard
September 2, 2021
Hybrid Heating and Air Conditioning
PO Box 329
Cornelius, OR 97113
Re: Permit No. MEC2021-00127
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 6911 SW Oak St
Project Name: Robinson
Job No.: N/A
Refund Method: ® Check#240420 in the amount of$83.78.
❑ Credit card"return"receipt in the amount of$ .
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,
,2%Lc��-/
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
. City of Tigard
T l V � Accela Refund Request
D
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: Hybrid Heating&Air Conditioning DATE: 8/27/2021
PO Box 329
Cornelius, OR 97113 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 433116 Case#: MEC2021-00127
Date: 2/25/2021 Address/Parcel: 6911 SW Oak St
Pay Method: CreditCard Project Name: Robinson
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 230-0000-43102 74.80
12%State Surchage 100-0000-24001 8.98
TOTAL REFUND: $83.78
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
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
r Case Refund Processed: Date: 9 21 By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIC.AR.i
Project Name: Robinson
Site Address: 6911 SW OAK ST
Receipt Number: 436278 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2021-00127 $-83.78
Total: $-83.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240420 DHOWSE 09/04/2021 $-83.78
Payor: Hybrid Heating and Air Conditioning
Total Payments: $-83.78
Balance Due: $83.78
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TiGAiD'
Project Name: Robinson
Site Address: 6911 SW OAK ST
Receipt Number: 433116 - 02/25/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2021-00127 Air Conditioning 230-0000-43102 $46.75
MEC2021-00127 Furnaces< 100K BTU 230-0000-43102 $46.75
MEC2021-00127 12%State Surcharge-Mechanical 100-0000-24001 $11.22
Total: $104.72
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7407387 PUBLICUSER107 02/25/2021 $104.72
Payor:
Total Payments: $104.72
Balance Due: $0.00
Page 1 of 1