Permit Support Document _erre/4;ml- 97.2=v2A)20
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT IA_ 74/ ,e()11/
a Request for Permit Action
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 ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Hybrid Heating and Air Conditioning
Mailing Address: PO BOX 329
City/State/Zip: Cornelius OR 97113
Phone No.: 503-357-5663
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICATION.
p REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
D INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MEC2020-00607
Site Address or Parcel#: 14306 SW WINDSONG CT
Project Name: LIVINGSTON
Subdivision Name: CASTLE HILL Lot#: 49
EXPLANATION: CUSTOMER CALLED AND CANCELED JOB.
Signature: 1 (OCL ) tY1C, ' Date: 09/29/2020
Print Name: c "yLr , ll• rr ..�'�
Refund Policy
1. The city's Community I •pment Director,Building Office 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 set-vice.
3. Please allow 3-4 weeks for processing refund requests. 702< l / /
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Route to Sys Admin: Date By Route to Records: Date 4, ei e•
Refund Processed: Date /?7/s-/ By /S() 'invoice Processed: Date By
Permit Canceled: Date F/ .7/a—/ By,a Parcel Tag Added: Date By
I:\Building\Forms\Rn PermitAction_t20518.doc
N
TIGARD
City of Tigard
September 2, 2021
Hybrid Heating and Air Conditioning
PO Box 329
Cornelius, OR 97113
Re: Permit No. MEC2020-00607
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14306 SW Windsong Ct
Project Name: Livingston
Job No.: N/A
Refund Method: ® Check#240420 in the amount of$80.64.
❑ Credit card"return" receipt in the amount of$
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
:Ili " City of Tigard
1 1 c n 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: Hybrid Heating&Air Conditioning DATE: 8/27/2021
PO Box 329
Cornelius, OR 97113 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 431022 Case#: MEC2020-00607
Date: 9/18/2020 Address/Parcel: 14306 SW Windsong Ct
Pay Method: CreditCard Project Name: Livingston
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: Bu 4ciitl Permit Fee � Ex Ample: 2300000-43104 $Amount
Permit Fee 230-0000-43102 $72.00
12%State Surchage 100-0000-24001 8.64
TOTAL REFUND: $80.64
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
@ n $ q$ $k
c-� .r. .,. .... .,, g ` ' r:+�( �i�r ' �,"C �y t) 0° C :' 7,1
Case Refund Processed: Date: 9 %i _j By: 1 04
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
lli CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Livingston
Site Address: 14306 SW WINDSONG CT Fit A✓_
Receipt Number: 436277 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M EC2020-00607 $-80.64
Total: $-80.64
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240420 DHOWSE 09/04/2021 $-80.64
Payor: Hybrid Heating and Air Conditioning
Total Payments: $-80.64
Balance Due: $80.64
Page 1 of 1
ih, CITY OF TIGARD RECEIPT
I. . 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T1GA Ir.D
Project Name: Livingston
Site Address: 14306 SW WINDSONG CT JJ z f / 4-1--
Receipt Number: 431022 - 09/18/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2020-00607 Air Conditioning 230-0000-43102 $46.75
MEC2020-00607 12%State Surcharge-Mechanical 100-0000-24001 $10.80
MEC2020-00607 Minimum Fee Adjustment-Mechanical 230-0000-43102 $43.25
Total: $100.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6823704 PUBLICUSER107 09/18/2020 $100.80
Payor:
Total Payments: $100.80
Balance Due: $0.00
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