Permit Support Document , . .
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT NO V 2 4 2020
11114 it
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Request for Permit Action ®p
U/tplivr, TIGARD
1 1(,Al2,1) 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov r.)V/SioN
TO: CITY OF TIGARD ( I
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Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 84A-X)
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: C Owner C Applicant Contractor K City Staff
Check(✓)one
REFUND OR Name: .- \
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INVOICE TO: (Business or Individual) �� c� -.. ...1 �)
Mailing Address: Pei 'i J( C,,?`" t
City/State/Zip: - 1f2-\)3C5-. 9CQ ^9 -Qc) L
Phone No.: — 1 t
P E TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
C INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: g 2 " CO s5 B.- T ,, /
Site Address or Parcel #: l ( ,,`„ t_.y 0 .. 2-
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Project Name: -; ( 9 3 3
Subdivision Name: Lot#:
EXPLANATION: G % 1"
Signature: c._--'' 5 � J°t�N`'—! Date: ( l._-2-4' 'rcjz—C—)
Print Name: 1,j ,, , cA tits--
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• Not more than 80%of the application or plan review fec when an application is withdrawn or canceled before review effort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. — s>L , /V
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l•OR.OFFICE (JSE ONLY
Route to Sys Admin: Date By Route to Records: Date e /.3 By .. ,7'
Refund Processed: Date/Z/e •24, B j`' �! Invoice Processed: Date , By
Permit Canceled: Date f'y-/ / ' By 4 C Parcel Tag Added: Date By
I:\Building\Forms\ReyPerinitocdon_,12tj5 f toe
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TIGARD
City of Tigard
December 22, 2020
S &A Electric, Inc.
PO Box 218
Boring, OR 97009
Re: Permit No. ELC2020-00585
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12345 SW Hall Blvd,29
Project Name: Tigard Terrace Apartments
Job No.: N/A
Refund Method: ® Check#237587 in the amount of$90.22.
❑ Credit card "return" receipt in the amount of$
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 they applied for the permit at the wrong unit#.
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
p 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 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 S &A Electric,Inc. DATE: 12/9/2020
TO:
PO Box 218
Boring, OR 97009 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 431882 Case#: ELC2020-00585
Date: 11/23/2020 Address/Parcel: 12345 SW Hall Blvd,29
Pay Method: CreditCard Project Name: Tigard Terrace Apartments
EXPLANATION: Per applicant's request as applied for permit at wrong unit#. Refund 80%of permit
fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $ Amount
Electrical Permit Fee 220-0000-43103 S80.56
12%State Surcharge 100-0000-24001 9.66
TOTAL REFUND: $90.22
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. OYV1.P.14
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
ootroNv
Case Refund Processed: Date: By.
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: E1922
Site Address: 12345 SW HALL BLVD 29
der-A76
Receipt Number: 435833 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00585 $-90.22
Total: $-90.22
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237587 DHOWSE 08/13/2021 $-90.22
Payor: S &A Electric Inc
Total Payments: $-90.22
Balance Due: $90.22
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CITY OF TIGARD RECEIPT
i II III 7 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: E1922
Site Address: 12345 SW HALL BLVD 29 o - t /6
Receipt Number: 431882 - 11/23/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00585 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2020-00585 12%State Surcharge-Electrical 100-0000-24001 $12.08
Total: $112.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7065590 PUBLICUSER118 11/23/2020 $112.78
Payor:
Total Payments: $112.78
Balance Due: $0.00
I
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