Permit Support Document VOID
et/A tee' RECEIVED
City of Tigard ' COMMUNITY DEVELOPMENT DEPARTMENT JUL4
111 I " 2021
Request for Permit Action CITY OF TIGARD
T(tA R f) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gaILDING DIVISION
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) 3 Mountains Plumbing
Mailing Address: 5304 N Albina Ave
City/State/Zip: Portland, OR 97217
Phone No.: 503-455-8838
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
I CANCEL/VOID PERMIT APPLICATION.
0 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#: PLM2021-00289
Site Address or Parcel#: 10717 SW 127th Ct, Tigard, OR 97223
Project Name: Ogorek Zbigniew Water Service
Subdivision Name: Lot#:
EXPLANATION: Work has been canceled
Signature: 4y tafr 2i12, Date: 07/14/2021
Print Name: Amanda Chezem
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fec 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. y? . s d r 4✓G /''fe 5
1/, 69; y fib. ay
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date ' ' Zf By
Refund Processed: DateP/ 7/a/ B34.06 Invoice Processed: Date By
Permit Canceled: Date e/37/>../ By,..e.,a6 Parcel Tag Added: Date By
I:\Building\Forms\RegPcrmicAction_12051 .doc
IIIq
TIGARD
City of Tigard
September 2, 2021
3 Mountains Plumbing
5304 N Albina Ave
Portland, OR 97213
Re: Permit No. PLM2021-00289
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10717 SW 127'Ct
Project Name: Zbigniew
Job No.: N/A
Refund Method: ® Check#240384 in the amount of$64.96.
❑ Credit card"return"receipt in the amount of$ .
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,
' ''..5--I;)(1,4--t-e.1.o t_.•.4--—'
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
_ p City of Tigard
�.<<; i a 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: 3 Mountains Plumbing DATE: 8/27/2021
5304 N Albina Ave
Portland, OR 97217 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 435206 Case#: PLM2021-00289
Date: 7/8/2021 Address/Parcel: 10717 SW 127th Ct
Pay Method: CreditCard Project Name: Zbigniew
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 230-0000-43101 $58.00
12%State Surchage 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager ti� ls/'2oY
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: L �Ay/",,, By: fir ,
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
!PI at 7 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Ogorek Zbigniev Water Service ,�/
Site Address: 10717 SW 127TH CT "(D
Receipt Number: 436276 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2021-00289 $-64.96
Total: $-64.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240384 DHOWSE 09/04/2021 $-64.96
Payor: 3 Mountains Plumbing
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
*' '. 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Ogorek Zbigniev Water Service
Site Address: 10717 SW 127TH CT
®i /G-/ 4/ ' '—
Receipt Number: 435206 - 07/08/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2021-00289 Water Service 230-0000-43101 $62.54
PLM2021-00289 12%State Surcharge-Plumbing 100-0000-24001 $8.70
PLM2021-00289 Minimum Fee Adjustment-Plumbing 230-0000-43101 $9.96
Total: $81.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7971595 PUBLICUSER107 07/08/2021 $81.20
Payor:
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1