Permit Support Document (2) RECEIVED v/
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 14
2020
Request for Permit Action CITY OFTIGARD
T I G A It 11 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigarc RIorPG 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) /;,.� -- / 80 ye M/.„-e (_f i.7
Mailing Address: l2 2- $ �!l o�9 '`tG
City/State/Zip: ,#°Q/Z-77. -A✓,6 O/2- 9 7 /C)
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
111 � �:��]�I�QID PERMIT APPLICATION.
,/0 REFUND IT FEES (attach copy of original receipt and provide explanation below).
INVOICEPOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ��/7-p-o .—)
Site Address or Parcel#: // 7, S14) S )—
Project Name: C
Subdivision Name: Lot #:
EXPLANATION: /4 r f --a— /'i S Cc 4
Pvt. "9--"Id YE / y •ct) /—a,--t-
Signature: `� Date: 57/4-011)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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date ) By ' �, Route to Records: Date Wcf 2! By 40-C
Refund Processed: Date = , Z/ By O Invoice Processed: Date By
Permit Canceled: Date A/, Byiell Parcel Tag Added: Date By
I:\Building\Forms\RcgPermitAction_120518.doc
IIIN
TIGARD
City of Tigard
February 11, 2021
Green Box Mechanical
3265 NW 29th Ave
Portland, OR 97210
Re: Permit No. PLM2020-00174
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 11735 SW Katherin St
Project Name: Finkle
Job No.: N/A
Refund: ® Check#238211 in the amount of$44.89.
❑ Credit card "return"receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Revised scope of work resulted in an overpayment of$44.89 to be refunded.
If you have any questions please contact me at 503.718.2430.
Sincerely,
rd7,
Dianna Howse
Building Division Services Coordinator
Enc.
I:\Building\RefundsA?1 Atgi'o'n\U Merpay.I 6J gpregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
■
1,1
City of Tigard
TIGARD 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: Green Box Mechanical DATE: 2/8/2021
3265 NW 29r1i Ave
Portland, OR 97210 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 429179 Case#: PLM2020-00174
Date: 4/28/2020 Address/Parcel: 11735 SW Katherine St
Pay Method: CreditCard Project Name: Finkel
EXPLANATION: Revised scope of plumbing permit work resulted in an overpayment to be refunded.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Cash Over 100-0000-48001 $44.89
TOTAL REFUND: $44.89
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. 9VV
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: A/y/Z/ By: /ej
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
IN
503.639.4171
II(�A it.1)
Project Name: Finkel
Site Address: 11735 SW KATHERINE ST /V.n
Receipt Number: 436264 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00174 $-44.89
Total: $-44.89
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 238211 DHOWSE 09/04/2021 $-44.89
Payor: Green Box Mechanical
Total Payments: $-44.89
Balance Due: $44.89
Page 1 of 1
CITY OF TIGARD RECEIPT
.1/11 111
Z 13125 SW Hall Blvd.,Tigard OR 97223
• 503.639.4171
TIGARD
Project Name: Finkel
Site Address: 11735 SW KATHERINE ST 02/6 (AI D.
Receipt Number: 429179 - 04/28/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00174 Lavatories 230-0000-43101 $25.02
PLM2020-00174 Tub/Shower/Shower Pan 230-0000-43101 $12.51
PLM2020-00174 Minimum Fee Adjustment-Plumbing 230-0000-43101 $34.97
PLM2020-00174 12% State Surcharge- Plumbing 100-0000-24001 $8.70
PLM2020-00174 Cash Over 100-0000-48001 $44.89
Total: $126.09
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6309691 PUBLICUSER198 04/28/2020 $126.09
Payor:
Total Payments: $126.09
Balance Due: $0.00
Page 1 of 1
Is
CITY OF TIGARD RECEIPT
111 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Finkel
Site Address: 11735 SW KATHERINE ST
Receipt Number: 429179 - 04/28/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00174 Lavatories 230-0000-43101 $25.02
PLM2020-00174 Tub/Shower/Shower Pan 230-0000-43101 $12.51
PLM2020-00174 Minimum Fee Adjustment-Plumbing 230-0000-43101 $34.97
PLM2020-00174 12% State Surcharge-Plumbing 100-0000-24001 $8.70
PLM2020-00174 Cash Over 100-0000-48001 $44.89
Total: $126.09
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6309691 PUBLICUSER198 04/28/2020 $126.09
Payor:
Total Payments: $126.09
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Finkel
Site Address: 11735 SW KATHERINE ST /2I6lA1'4 e--.-
Receipt Number: 429179 - 04/28/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00174 Water Piping/DWV 230-0000-43101 $112.58
PLM2020-00174 12% State Surcharge- Plumbing 100-0000-24001 $13.51
Total: $126.09
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6309691 PUBLICUSER198 04/28/2020 $126.09
Payor:
Total Payments: $126.09
Balance Due: $0.00
Page 1 of 1