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Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED ED Request111 for Permit Action TUG CITY O F 2020 F TIGARD T i G A R t) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •\vww.tigar.W aIG DIVISION TO: CITY OF TIGARD VO I Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 / 2/q/7 �U Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner © Applicant Contractor ❑ City Staff Check(1)one REFUND OR Name: ��{�j, A /y INVOICE TO: (Business or Individual) c-DVna/ {-.,) !s _J a / y Mailing Address: a?� a�5 /I;/WIS, eR 7 City/State/Zip: 'D/7`?'Q11 CLJ D6 9767 Phone No.: 503- C7 77/ ..e ..'05/ PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): [' CANCEL/VOID PERMIT APPLICATION. ® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: E4c eRORe)--Qd Site Address or Parcel#: /6.7m u)L a1' Project Name: �Ui ,�- jj/)�A 4 Subdivision Name: /99V-Oo?e �CjyJ�jCQ✓� Toh_74-- Lot#: EXPLANATION: 6 ems/ 6,1 4a�, , ,-% &'fit /7a f.✓G►GL _ 6.Q r4D 01 d / tJ31-- „ -,Y).-Z (/.o hms rerteel Signature: ate: 23/3/Re"" Print Name: .14 a 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 9. , LP 1©y, '7 f ' - , 90 hUR ()1 (-ICE USE ONLY Route to Sys Admin: Date By Route to Records: Date 1'f''1"3 2_ By 4d Refund Processed: Date,2./c7/2„) B j Invoice Processed: Date By Permit Canceled: Date /2-/<j/2.e B 4/I: Parcel Tag Added: Date By I:\Building\Forms\ReyPcnnitAction_120518.doc 111 n p TIGARD City of Tigard December 22, 2020 Dynalectric 2225 NW 20th Ave Portland, OR 97209 Re: Permit No. ELC2020-00402 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 16200 SW Pacific Hwy Project Name: Spec Space Job No.: N/A Refund Method: ® Check#237546 in the amount of$83.57. ❑ Credit card "return" receipt in the amount of$ 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 job was awarded to another contractor. 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 C " 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 Dynalectric DATE: 12/9/2020 TO: 2225 NW 20th Ave Portland, OR 97209 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 403566 Case#: ELC2020-00402 Date: 08/10/2020 Address/Parcel: 16200 SW Pacific Hwy,K Pay Method: CreditCard Project Name: Spec Space EXPLANATION: Per applicant's request as job was awarded to another contractor. Refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit knee Example: 2300000-43104 $Amount Electrical Permit Fee 220-0000-43103 $74.62 12%State Surcharge 100-0000-24001 8.95 TOTAL REFUND: $83.57 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff 77�,, � If under$12,500 Division Manager D. L. Orne2a4 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: By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 71 q CITY OF TIGARD RECEIPT t 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Suite K-Make Ready Site Address: 16200 SW PACIFIC HWY K �6-' tL Receipt Number: 435830 - 08/13/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2020-00402 $-83.57 Total: $-83.57 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 237546 DHOWSE 08/13/2021 $-83.57 Payor: Dynalectric Total Payments: $-83.57 Balance Due: $83.57 Page 1 of 1 q CITY OF TIGARD RECEIPT IIIIa 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Suite K-Make Ready Site Address: 16200 SW PACIFIC HWY K Receipt Number: 430566 - 08/10/2020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2020-00402 Branch Circuits wo/Purchase Service or 220-0000-43103 $93.28 Feeder ELC2020-00402 12%State Surcharge-Electrical 100-0000-24001 $11.19 Total: $104.47 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 6669700 PUBLICUSER107 08/10/2020 $104.47 Payor: Total Payments: $104.47 Balance Due: $0.00 Page 1 of 1 Lynne McEachern From: PayGov <no-reply@paygov.us> Sent: Monday,August 10, 2020 10:48 AM To: Lynne McEachern Subject: Order Receipt 6669700 :DV!SEC. Ti's email originated outside EMCOR. This email is a confirmation of your Online Payment for PERMIT CENTER Cardholder Name: Lynne McEachern Telephone : : (503)226-6771 Credit Card Type :Visa Last 4 digits :4XXX XXXX XXXX 7799 Confirmation Number:6669700 Card Auth Code :028100 Transaction ID : 1758432934 Agency Payment Amount: $104.47 Convenience Fee : $3.13 Total Amount Charged :$107.60 First Name:Lynne Last Name:McEachern Your payment to PERMIT CENTER has been processed by PayGov, LLC. NOTICE.Two charges will appear on your credit card or bank statement. One is for the Tax, Fine,or Fee owed to the government agency and will reflect the name of the agency. The other is for the convenience fee assessed by Pa'vGOV.US and will reflect"Convenience Fee" on your statement. For questions or concerns contact i ayGO'V.US at 1-866-480-8552.Transaction disputes will result in a $40 charge to the cardholder. i