Permit Support Document ‘ if
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ai DECCity of Tigard • COMMUNITY DI�.\'1{1.OPNII?N" 1)I?1 .\R'1'N11�.NT D 3
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Request for Permit Action BweprN C17y0F l ,
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • \4\vw.ti Yard-or.(ro •
TO: CITY OF TIGARD DEC 3 !v
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Building Division 4 2020
13125 SW Hall Blvd.,Tigard,OR 97223 R CiTYOF
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPernuts@tigard-c G p��SRt)
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FROM: ❑ Owner 3 Applicant ❑ Contractor ❑ City Staff
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REFUND OR Name: •
INVOICE TO: (ISusines.or Individual) \ ► \.QA' �1b1 \ .
Mailing Address Ott-V.120 Sly'\` ucc\ dai�S \6\
City/State/Zip: , ‘CSKAck ca_
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Phone No.: )3-L4 -S2Ci (p
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
!I CANCEL/VOID PERMIT APPLICATION.
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 #: -M 00 - (h12.
Site Address or Parcel#: V. QkdOGunn( At .p, f Tine l 4 - 2 LI
Project Name: SOM K 5\�Q. `JJ n i n A6045CO
Subdivision Name: max-�QJt;\( 'Q__ Lot#: 12
EXPLANATION: �1L� m t Vt--'nc)-(L\ I 2
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Signature: t 1 Date: )Q131 f _O
Print Name: L ;n
Refund Policy
I. The cit's Community Development Director,Building()fficial or City I..ngineer may authorize the refund of:
• .\nv 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. .\ll refunds will be returned to the original paver in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys.Amin: Date Be Route to Records: Date y 2./ B' _e
Refund Processed: Date 21/Z/ By SO InvoiceProcessed: Date By
Permit Canceled: Date 1 LI d 2-I By Q Parcel Tag Added: Date By
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TIGARD
City of Tigard
February 11, 2021
Western Plumbing Inc.
9460 SW Tigard St, Suite 101
Tigard, OR 97223
Re: Permit No. PLM2020-00512
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14405 SW 92°d Ave
Project Name: Stern Residence
Job No.:
Refund Method: ® Check#238256 in the amount of$462.36.
❑ Credit card "return"receipt in the amount of$
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): Void permit as all work performed under master permit MST-00017.
Refund 100% of permit fees paid under separate plumbing permit PLM2020-00512.
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
City of Tigard
T i G n K u 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: Western Plumbing DATE: 2/8/2021
9460 SW Tigard St, Suite 1
Tigard, OR 97223 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 432279 Case#: PLM2020-00512
Date: 12/23/2020 Address/Parcel: 14405 SW 92nd Ave
Pay Method: CreditCard Project Name: Stern
EXPLANATION: Refund 100%of permit fees as all scope of work completed under MST2021-00017.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
i Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit 230-0000-43101 $412.82
12% State Surcharge 100-0000-24001 49.54
TOTAL REFUND: $462.36
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff �7,,
If under$12,500 Division Manager D. L. DYV�
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: 9/4/l2-1 By: 0,
I I:\Building\Refunds\RefundRequest.doc x 09/01/2010
IN CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Stern Residence
Site Address: 14405 SW 92ND AVE
/0.\
Receipt Number: 436261 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00512 $-462.36
Total: $-462.36
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 238256 DHOWSE 09/04/2021 $-462.36
Payor: Western Plumbing Inc.
Total Payments: $-462.36
Balance Due: $462.36
Page 1 of 1
CITY OF TIGARD RECEIPT
114
i g. , 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T I i;\I'.1.)
Project Name: Stern Residence
Site Address: 14405 SW 92ND AVE 64(6 r
Receipt Number: 432279 - 12/23/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00512 Clothes Washer 230-0000-43101 $25.02
PLM2020-00512 Dishwasher 230-0000-43101 $25.02
PLM2020-00512 Hose Bib 230-0000-43101 $50.04
PLM2020-00512 Ice Maker 230-0000-43101 $12.51
PLM2020-00512 Sink 230-0000-43101 $50.04
PLM2020-00512 Laundry Tray 230-0000-43101 $25.02
PLM2020-00512 Lavatories 230-0000-43101 $75.06
PLM2020-00512 Tub/Shower/Shower Pan 230-0000-43101 $37.53
PLM2020-00512 Water Closet 230-0000-43101 $75.06
PLM2020-00512 Water Heater 230-0000-43101 $37.52
PLM2020-00512 12% State Surcharge- Plumbing 100-0000-24001 $49.54
Total: $462.36
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7169381 PUBLICUSER107 12/23/2020 $462.36
Payor:
Total Payments: $462.36
Balance Due: $0.00
Page 1 of 1
I.
CITY OF TIGARD `S Li
i`w PLUMBING PERMIT
s . COMMUNITY DEVELOPMENT Permit#: PLM2020-00512
p EIe2-1"1 1 Date Issued: 12/23/2020
T I(_ A i;f-) 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 is TN-)14i Parcel: 2S111AB04500
0 Al L.1 r.I ( Jurisdiction: Tigard
Site address: 14405 SW 92ND AVE
Project: Stern Residence Subdivision: PENMAR TERRACE Lot: 12
Project Description: Interior Remodel
Contractor: WESTERN PLUMBING Owner: STERN, KAREN ROBIN
9460 SW TIGARD AVE SUITE 101 14405 SW 92ND AVE
TIGARD, OR 97223 ARD FOR 97224
PHONE: 503-639-5296 PHONE:
FAX: 503-684-9015
)Es
Quan ity Descriptio Date Amount
1 a Clothes Washer 12/23/2020 $25.02
Specifics: 1 e Dishwasher 12/23/2020 $25.02
2 ea Hose Bib 12/23/2020 $50.04
Type of Use: SF r 1 ea a Maker 12/23/2020 $12.51
Class of Work: ALT 2 ea S k 12/23/20 % $50.04
Type of Const: 1 ea Lau dry Tray 12/ • 2020 $25.02
Occupancy Grp: 3 ea Lavatories 2/23/2020 $75.06
Stories: 3 ea Tub/Shower/Shower Pan 12/23/2020 $37.53
3 ea Water Closet 12/23/2020 $75.06
1 ea Water Heater 12/23/2020 $37.52
1 12%State Surchart- - 12/23/2020 $49.54
Plumbing
Total $462.36
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Issued By: Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.