Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT W)V 1 2 ZOZO
a
Request for Permit Action cm OfTIGRRJ
aultDING DIVISION
TIGARD. 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division voi
13125 SW Hall Blvd.,Tigard,OR 97223 ty,\
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov /2////7 A�V
FROM: [ Owner ES Applicant LI Contractor ( City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ^> LL t!
Mailing Address: ---7Ct45Ct ( ( r f I C r
City/State/Zip: l (Q ve,A ,_ (3 R bOq
Phone No.: Cj(/— L( (o C1 "'7 a ,-( (
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Z1 CANCEL/VOID PERMIT APPLICATION.
nREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below),
Permit#: S__ LO
Site Address or Parcel#: L{e 2D s - `?1 A 1 - 72 v- >Ave
Project Name: (J--e U 'Get
Subdivision Name: Lot#:
EXPLANATION: atk ( kr_t,
Signature: LAr Date: (Z ( z
Print Name: Lr,sf \ V-VNG"\ `1- to
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. .7` __0 r H - jS
639. rt 6 7. 40 / .tea
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date ?Alp/ By/4
Refund Processed: Date/Z/uf By,0 Invoice Processed: Date ' By
Permit Canceled: Date /t- ti 7-4,1 By f O Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 18.d oc
u1
•• i
TIGARD
City of Tigard
December 22, 2020
ADT LLC
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2020-00097
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14835 SW 72"d Ave
Project Name: Geo Pacific Engineering
Job No.: N/A
Refund Method: ® Check #237529 in the amount of$67.20.
❑ Credit card"return" receipt in the amount of$
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 changed scope of work and permit was no
longer required. 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
TIGARn 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 ADT LLC DATE: 12/9/2020
TO:
7989 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 430414 Case#: ELR2020-00097
Date: 7/29/2020 Address/Parcel: 14835 SW 72nd Ave
Pay Method: CreditCard Project Name: Geo Pacific Engineering
EXPLANATION: Per applicant's request as changed scope of work and permit was no longer needed;
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 l,ee 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. °mute,
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
Ai)M+,Nisi Arco A ti C 1 +V`
Case Refund Processed: Date: r f/3/2/ By: er 6)
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
q
CITY OF TIGARD RECEIPT
s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Geo Pacific Engineering
Site Address: 14835 SW 72ND AVE 2&—" .n/A
Receipt Number: 435832 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2020-00097 $-67.20
Total: $-67.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237529 DHOWSE 08/13/2021 $-67.20
Payor: ADT LLC
Total Payments: $-67.20
Balance Due: $67.20
Page 1 of 1
CITY OF TIGARD RECEIPT
111 it ; 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Geo Pacific Engineering
Site Address: 14835 SW 72ND AVE
Receipt Number: 430414 - 07/29/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2020-00097 Restricted Energy Permit 220-0000-43103 $75.00
ELR2020-00097 12% State Surcharge-Electrical 100-0000-24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6626584 PUBLICUSER107 07/29/2020 $84.00
Payor:
Total Payments: $84.00
Balance Due: $0.00
Page 1 of 1