Permit Support Document v 0 ! D RPrFivi- D
i.6' e 40
City of Tigard • COMMUNITY DEVELOPMEN DL7PARTMENT JUN 0 9 0 2 20
Request for Permit Action CITY OFT!GARD
i 1,,A 1) 13125 SW Hall Blvd. •Tigard, Oregon 97223 . 503-718-2439 • www.tigard-o �s( #NG DIVISION
It
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 ii. Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
1
INVOICE TO: (Business or Individual) y 104t,r tti S l,,.,01,,,,,,to 1 4.1
Mailing Address: P,0 f3 . 6
City/State/Zip: '"l uc;Ae ,.,,,_ 0 Q cf." 06.. -,
Phone No.: Sol - 6 Q . • c.. l 3l
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
MREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: f L A , .OaO - 0 t? _g/
Site Address or Parcel #: t t 7 5 c( SW ,� We.,A. c, LP
Project Name: Wet}e,r' S.e.e•V 1 Ge k 1 to 6--
Subdivision Name: Lot#:
EXPLANATION: pu c t ,c a4.e Fexw{., .\- 5— (LNI 20 20-DD Al 7
Signature: J r�� Date: [g— --, (�
Print Name: Aj1?LQ 1,1ct tit 4A--
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. _- / ;so
1'012 OFFICE I SE ONLY
Route to Sys Admin: Date B Route to Records: Date.: 7,1 B, -/
Refund Processed: Date 2.1 ./) WO Invoice Processed: Date By
Permit Canceled: Date (_ 249 Reo Parcel Tag Added: Date By
1:\Building\Forms\RegPermitAcrion_l2 518. oc
r lor
TIGARD
City of Tigard
February 11, 2021
Rayborn's Plumbing
PO Box 69
Tualatin, OR 97062
Re: Permit No. PLM2020-00228
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11759 SW Swenden Lp
Project Name: King
Job No.:
Refund Method: ® Check#238241 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 obtained duplicate permit in error; see
PLM2020-00217 for work performed. 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
City of Tigard
I.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 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: Rayborn's Plumbing DATE: 2/8/2021
PO Box 69
Tualatin, OR 97062 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 429602 Case #: PLM2020-00228
Date: 6/2/2020 Address/Parcel: 11759 SW Swendon Lp
Pay Method: CreditCard Project Name: King Water Service
EXPLANATION: Duplicate permit obtained in error;refund 80% of permit fees paid.
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
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff ' ,,7,,,
If under$12,500 Division Manager D. L. Ory ei c(4
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: (7) By:
I:ABuilding\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
-1 j'., 13125 SW Hall Blvd.,Tigard OR 97223
Ill503.639.4171
TIGARD
Project Name: Water Service
Site Address: 11759 SW SWENDON LOOP
Receipt Number: 436266 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00228 $-64.96
Total: $-64.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 238241 DHOWSE 09/04/2021 $-64.96
Payor: Rayborn's Plumbing
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
1111
503.639.4171
TIC,AP. 1)
Project Name: Water Service
Site Address: 11759 SW SWENDON LOOP
Receipt Number: 429602 - 06/02/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2020-00228 Water Service 230-0000-43101 $62.54
PLM2020-00228 12% State Surcharge- Plumbing 100-0000-24001 $8.70
PLM2020-00228 Minimum Fee Adjustment-Plumbing 230-0000-43101 $9.96
Total: $81.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6420557 PUBLICUSER107 06/02/2020 $81.20
Payor:
Total Payments: $81.20
Balance Due: $0.00
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