Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Of JUL 1 � 2019
= Request for Permit Action CITY OF TIGARD
T 1 G A RE) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ww_w_Ls_g a stuitANG Divisoo V
TO: CITY OF TIGARD l
Building Division 7/ J 19r -4,
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) R p\w VD\-N-k
Mailing Address: ' *1 C*-•• 1.0
City/State/Zip: vc-t-r‘c=c `(4- Ct%l10
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCFT /VOID PERMIT APPLICATION.
V' REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide tion below .
Permit#: \( (j" - c SWCZ UCra;-0 WC3
Site Address or Parcel#: \Q29S."\- Sly SU.x\clr\VNL C a c - Sk .
Project Name: RO\ jC\0f1
Subdivision Name: r .05 - -2-+ e-' Lot#: 0-5g,
EXPLANATION: R-62.4.1-cA S &w "DLkk( ". .
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Signature: Date: 9-115'\67i
Print Name: S 1-'Th\QS
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Adnvn: Date'-•I Mil lQ By c -C Route to Records: Date • 1-11111w B
Refund Processed: Date 1/5/ - B .:' Invoice Processed: Date I; - B .'
Permit Canceled: Date 7/ /j 9 By 4eAt.---.12ikreel Tag Added: Date By
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City of Tigard
August 9, 2019
Polygon WLH LLC
703 Broadway Street, Suite 510
Vancouver,WA 98660
Re: Permit No. MST2019-00064 SWR2019-00055
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16887 SW Sunshine Coast
Project Name: Polygon at Roshak Ridge,Lot 128
Job No.: N/A
Refund Method: ® Check#232940 in the amount of$18,731.77.
❑ Credit card "return" receipt in the amount of$
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): Resubmitted new plans under MST2019-00302 &SWR2019-00231.
Refund 100% of permit fees and system development fees,less plan review fees for plan
review already completed.
If you have any questions please contact me at 503.718.2430.
Sincere ,
Dianna Howse
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
TIGARll 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 forPermit 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: Polygon WLH LLC DATE: 8/5/2019
703 Broadway St,Ste 510
Vancouver,WA 98660 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 422829&422830 Case#: ui.200 664&
SWR2019-00055
Date: 4/16/2019 Address/Parcel: 1 uns e Coast
Pay Method: Check Project Name: Polygon at Roshak Ridge, 128
EXPLANATION: Resubmitted new plans under new permit(MST2019-00302&SWR2019-00231).
Refund 100% of permit fees paid.
REFUND INFORMATION
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Building Permit 230-0000-43104 $1,596.84
Mechanical Permit 230-0000-43102 324.32
Electrical Permit 220-0000-43103 345.30
Plumbing Permit 230-0000-43101 500.32
12%State Surcharge 100-0000-24001 332.03
Tig-Tual School CET 230-0000-24102 2,701.40
Metro Const. Excise Tax 230-0000-24010 317.16
Erosion Control permit 640-0000-43134 311.40
Tigard Trans SDC Reimbursement 415-0000-43301 343.00
Parks SDC Improvement 425-0000-43300 4,914.00
Parks SDC Reimbursement 425-0000-43301 1,361.00
Sewer Connection Permit 500-0000-25500 5,650.00
Sewer Inspection 230-0000-43118 35.00
TOTAL REFUND: $18,731.77
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
431
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
I:\Building\Refunds\RefundRequest.doc x 12/21/2016 (`Iy/ c)
CITY OF TIGARD RECEIPT
it 14 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Polygon at Roshak Ridge, Lot 128
Site Address: 16887 SW SUNSHINE COAST ST
Receipt Number: 434704 - 06/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
S W R2019-00055 $-5,685.00
Total: $-5,685.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 232940 DHOWSE 06/04/2021 $-5,685.00
Payor: Polygon WLH, LLC
Total Payments: $-5,685.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Polygon at Roshak Ridge, Lot 128
Site Address: 16887 SW SUNSHINE COAST ST ,,' (6-1 r/ L—
Receipt Number: 422830 - 04/16/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2019-00055 Sewer Connection Fee 500-0000-25500 $5,650.00
SWR2019-00055 Sewer Inspection-Residential 230-0000-43118 $35.00
Total: $5,685.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 72631 DHOWSE 04/16/2019 $5,685.00
Payor: Polygon WLH, LLC
Total Payments: $5,685.00
Balance Due: $0.00
Page 1 of 1