Permit Support Document (2) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ 0 1 0
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TIGARD 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 TigardBuildingPennits@tigard-or.gov
FROM: ❑ Owner [I Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: /� 1"
INVOICE TO: (Business or Individual) 5;1 v tr hi o un{ a;,(1 1' I U.vvl Orr i A.j 2-:h ,, .
Mailing Address: I L1-7 3 5 '1?O,n�y,'a. '(,, '
City/State/Zip: �j�e..t-y qtt-. v, , D 2_ c} - uv --1
Phone No.: .5 3.. to t.I 14 - 0-1 D 3
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
1){j CANCEL/VOID PERMIT APPLICATION.
R 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#: P lT V1\ 'DO l .- D O 1 to l
Site Address or Parcel#: _j LI$t-L S S uo i U o`-' A V e . t Ti 4 cud, GJ'2 4 7, 'D 14
Project Name: I J 0,,i 2v. ,r-�S;01 .Q ,J e
Subdivision Name: Lot#:
EXPLANATION: A/l y c eye. /9y-r"s:!✓ ekt-t.a.;1Lc/ h'1O r a v9,-1 t 1,011 s o,) S'-}ti(1
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Signature: �( na. )2>!O /umNiv.P Date: 5/r)/a r
Print Name: `
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. .J..z . 7..3 , 50 r!., 6, ✓z . .5f
7. 53 3o .dz 7_ 5/
Route to Sys Admin: Date By Route to Records: Date 9/ri y By e01._
Refund Processed: Date,17?-7/e- 1:34ee Invoice Processed: Date ! By
Permit Canceled: Date 4l / 7/?i By.2C' Parcel Tag Added: Date By
1:\Building\Forms\RegPemvulction_20518.doc
114 a
TIGARD
City of Tigard
September 2, 2021
Silver Mountain Plumbing Inc.
14735 SW Bonanza Ct
Beaverton, OR 97007
Re: Permit No. PLM2021-00161
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14845 SW 100th Ave
Project Name: Barton
Job No.: N/A
Refund Method: ® Check#240443 in the amount of$280.20.
❑ Credit card"return"receipt in the amount of$
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 work was performed by another contractor.
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
11111
N City of Tigard
T I G A 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: Silver Mountain Plumbing, Inc. DATE: 8/27/2021
14735 SW Bonanza Ct
Beaverton, OR 97007 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 433890 Case#: PLM2021-00161
Date: 4/19/2021 Address/Parcel: 14845 SW 100th Ave
Pay Method: CreditCard Project Name: Barton
EXPLANATION: Per applicant's request as work was performed by another contractor. 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 $250.18
12%State Surchage 100-0000-24001 30.02
TOTAL REFUND: $280.20
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager ' P ft,,,i,,,,,,_)
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
' ems.
Case Refund Processed: I Date: Cf y�� By: "Cr
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
t 14_;i1.R.D
Project Name: Barton residence
Site Address: 14845 SW 100TH AVE
Receipt Number: 436274 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2021-00161 $-280.20
Total: $-280.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240443 DHOWSE 09/04/2021 $-280.20
Payor: Silver Mountain Plumbing Inc
Total Payments: $-280.20
Balance Due: $350.26
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TtG;A IT.D
Project Name: Barton residence
Site Address: 14845 SW 100TH AVE
Receipt Number: 433890 - 04/19/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2021-00161 Sanitary Sewer 230-0000-43101 $62.54
PLM2021-00161 Water Service 230-0000-43101 $62.54
PLM2021-00161 Clothes Washer 230-0000-43101 $25.02
PLM2021-00161 Hose Bib 230-0000-43101 $50.04
PLM2021-00161 Sink 230-0000-43101 $25.02
PLM2021-00161 Lavatories 230-0000-43101 $50.04
PLM2021-00161 Tub/Shower/Shower Pan 230-0000-43101 $12.51
PLM2021-00161 Water Closet 230-0000-43101 $25.02
PLM2021-00161 12%State Surcharge-Plumbing 100-0000-24001 $37.53
Total: $350.26
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7637605 PUBLICUSER111 04/19/2021 $350.26
Payor:
Total Payments: $350.26
Balance Due: $0.00
Page 1 of 1
Dianna Ornelas
From: Deanna Gohl <silvermountainplumbing@msn.com>
Sent: Tuesday, May 11, 2021 10:22 AM
To: #Building Permit Technicians
Cc: Marianne Wilson Stein
Subject: Plumbing Permit#: PLM2021-00161
Attachments: Silver Mountain Plumbing - Plumbing Permit PLM2021-00161 Refund Request -
5-11-2021.pdf
Follow Up Flag: Follow up
Flag Status: Completed
Categories: Holly
Caution!This message was sent from outside your organization.
Hello,
I am writing to request cancellation of Plumbing Permit#PLM2021-00161, for the site address 14845 SW
100th Ave., Tigard. Attached please find the completed Request for Permit Action, the Plumbing Permit, and
the April 19 Order Receipt 7637605 for $350.26 in permit fees.
This cancellation is at the request of Allyson Armstrong. As per her email to Marianne Wilson Stein at L.S.
Panas & Assoc. on May 10, trade permits for this project are to be issued under one master permit, and the
plumbing permit will be void.
Please let me know if you need additional information to process the refund.
Thank you,
Deanna
Deanna Gohl
OwnerN.P.
Silver Mountain Plumbing, Inc.
14735 SW Bonanza Ct.
Beaverton, OR 97007-5903
503-644-2123 (phone)
503-574-3252 (fax)
503-267-4574 (Rich's cell phone)
silvermountainplumbing@msn.com
CCB#: 156766
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