Permit Support Document V
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
!PI = Request for Permit ActionV 0 1
'TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov l v z(1
c)
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tiga -or.gov
FROM: ❑ Owner ❑ Applicant El Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: / 1/03 A/O/L-7 4 £ -/G EC Ai l
City/State/Zip: D/I 71 r P . 9 7
Phone No.: (P.S_S' ZO S _ e
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
prNCEL/VOID PERMIT APPLICATION.
EFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: r GC- .-00 i j3/
Site Address or Parcel #: /3 7.5- -fit/ `/.5 MAC-
Project Name: %/ZAJ-P,"
Subdivision Name: Lot #:
EXPLANATION: /�Ei✓1/V�� eteej9f?9O 1 L1-rego'L. . EC ,:rTetcirt.:
tocg1it1% re) be /Alai-W-6 w/ x•fsrzozr, 2 53 . fc S (4/ t= P/1-aj
Did L.-We f'l s6-' ague 2Er-wA/1.) Ar /g-v`'7d
Signature: Date: /d -06 Z.O2.
Print Name: 6-G4ie A-CDO? VifoO
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 c 'a US postal service.
3. Please allow 3-4 weeks for processing refund re•.
00 • 7d .yam
FOR OFFICE I('l I'SE ONLY
Route to Sys Admin: Date 70 . '-71.1"1y -7/ Route to Records: Date '/7/7_4' By ✓e
Refund Processed: Date /z j g/, By,9 Invoice Processed: Date // By
Permit Canceled: Date ,j/q/ j By Q Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120 8.doc
1111 v
TIGARD
City of Tigard
December 22, 2020
BRS Field Ops LLC
1403 North Research Way
Orem, UT 84097
Re: Permit No. ELC2020-00431
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13575 SW 115th Ave
Project Name: Trapp
Job No.: N/A
Refund Method: ® Check#237537 in the amount of$112.78.
❑ Credit card"return" receipt in the amount of$
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): Permit was created in error by city staff and all fees were paid by
applicant. Refund 100% of permit fees paid.
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
,w .
III
'' I _ City of Tigard
TIGAR[) 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 BRS FIELD OPS LLC DATE: 12/9/2020
TO:
1403 North Research Way
Orem, UT 84097 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 430943 Case #: ELC2020-00431
Date: 09/08/2020 Address/Parcel: 13575 SW 115th Ave
Pay Method: CreditCard Project Name: Trapp
EXPLANATION: Permit created in error per Eggie Maldonado, see MST2020-00253. Refund 100%of
fees paid.
REFUND NFORMAT Ni w r ' VI. 'i s cars a , ., 6r,, ,
Fee Description From Receipt Revenue Account No. Refund ..
Example: Building Permit Fee'!' m Fxample: '';2300000.43104 $Amount
Electrical Permit Fee 220-0000-43103 $100.70
12%State Surcharge 100-0000-24001 12.08
TOTAL REFUND: $112.78
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. OVP.e
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
S)ors;:, t , x r PO*Atw.✓E..eaA'0SrtT ADMngrg kAt„t/4�It SE' j,,,l,„,,ft.rif;;','4„....-..,
., o ;, .Case Refund Processed: Date c//,3�J-/ By: a
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
114 CITY OF TIGARD RECEIPT
1 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Trapp
Site Address: 13575 SW 115TH AVE
Receipt Number: 435831 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00431 $-112.78
Total: $-112.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237537 DHOWSE 08/13/2021 $-112.78
Payor: BRS Fields Ops LLC
Total Payments: $-112.78
Balance Due: $112.78
Page 1 of 1
CITY OF TIGARD RECEIPT
! S 7 14 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Trapp
Site Address: 13575 SW 115TH AVE 0 x (cTl/`m-f1
Receipt Number: 430943 - 09/08/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00431 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2020-00431 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 6778407 PUBLICUSER228 09/08/2020 $112.78
Payor:
Total Payments: $112.78
Balance Due: $0.00
Page 1 of 1