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Permit Support Document RECEIVED City ©f Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ,JAN 1 2 2021 1711 , 4 CITY TIGARD Request for Permit Action BOFUILDING DIVISION 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD ,r7 V 0 ) Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 We)/ Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits®tigard-or.gov FROM: D Owner 0 Applicant 21-Contractor 0 City Staff Check(,)unr REFUND OR Name: INVOICE TO: Business or individual) e Ps.%Lis Mailing Address: I S Lki City/State/Zip: -y-k fJ, ?_ Phone No.: S 0 - SR- 626f Lig PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): : • CANCEL/VOID PERMIT APPLICATION. El REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). 0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit #: eLA (- 000 ‘s. Site Address or Parcel #: CbC. tp GO Ii okettooX- C)K Project Name: S 40(4-0"1/4.0.-eN Subdivision Name: 11/4-1 kA Lot#: 4013 EXPLANATION: Cc. IL . - • N _ .._ 5 ) CkS--(0.'“) N U24-000/ Signature: Date: I 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. • Nor more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. Ali refunds will be returned to the original payer in the form of check via US postal service. 3. Please 3-4 weeks for processing refund requests. 5-0 _ - FOR OFFICE t SE ONLY Route to Sys Admits: Dare By Route to Records: Dare Lf -./ By S4IF Refund Processed: Date litcrie-/ , By Invoice Processed: Date By Permit Canceled: Date ariezi By 4E Parcel Tag Added: Date Bv Wivilding\Forins\kcyPcnnitAxtion_110,5hdoc a p TIGARD City of Tigard February 11, 2021 The Plumbers Inc 11420 SW Pacific Hwy Tigard, OR 97223 Re: Permit No. PLM2021-00015 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 15680 SW Alderbrook Cir Project Name: Keith Davis Hootman Job No.: Refund Method: ® Check#238248 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 permit was obtained for the wrong address; see PLM2021-00016 for work at correct address. 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 t IN ■ " City of Tigard i �; E, Accela Refund Request I_ 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: The Plumbers Inc DATE: 2/8/2021 11420 SW Pacific Hwy Tigard, OR 97223 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 432462 Case#: PLM2021-00015 Date: 1/12/2021 Address/Parcel: 15680 SW Alderbrook Cir Pay Method: CreditCard Project Name: 20-521 EXPLANATION: Per applicant's request as obtained permit for wrong address (see PLM2021-00016). Refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount Plumbing Permit 230-0000-43101 $58.00 12%State Surcharge 100-0000-24001 6.96 1 TOTAL REFUND: itlir2r1: APPROVALS: SIGNATURES/DATE: V ti 9`�, ° If under$5,000 Professional Staff If under$12,500 Division Manager D. L. Orh.ela4 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: q(. (24 By: 4! I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT III $ 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIL AR.I.) Project Name: 20-521 Site Address: 15680 SW ALDERBROOK CIR C.Ai®\ Receipt Number: 436262 - 09/04/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2021-00015 $-64.96 Total: $-64.96 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 238248 DHOWSE 09/04/2021 $-64.96 Payor: The Plumbers Inc. Total Payments: $-64.96 Balance Due: $64.96 Page 1 of 1 ... . U CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: 20-521 Site Address: 15680 SW ALDERBROOK CIR I , Receipt Number: 432462 - 01/12/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2021-00015 Clothes Washer 230-0000-43101 $25.02 PLM2021-00015 Laundry Tray 230-0000-43101 $25.02 PLM2021-00015 12% State Surcharge-Plumbing 100-0000-24001 $8.70 PLM2021-00015 Minimum Fee Adjustment-Plumbing 230-0000-43101 $22.46 Total: $81.20 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 7236545 PUBLICUSER107 01/12/2021 $81.20 Payor: Total Payments: $81.20 Balance Due: $0.00 Page 1of1