Permit Support Document RECEIVED �-
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUL 2 4 20?IJ
111 Request for Permit Action CITY OFTIGARD
BU
T I G A It D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigarrd or go G DIVISION
TO: CITY OF TIGARD 0
Building Division q/2-0
<9z
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner X ] Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) EC Company
Mailing Address: PO Box 10286
City/State/Zip: Portland, OR 97296
Phone No.: 503-220-3528
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
x CANCEL/VOID PERMIT APPLICATION.
U 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#: ELC2020-00370
Site Address or Parcel #: 9095 SW Burnham, Tigard, OR
Project Name: 77861 Tigard Universal Plaza
Subdivision Name: Lot#:
EXPLANATION: Wrong site address. Cie,26 'Zp -- 0O3 72
Digitally signed byCariie Mason Signature: Date:2020.07.24 O.5 :t t-07 00 Date: 7,2 q,2020
Print Name: Carrie Mason
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee winch 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
90 - 7, /2— - /• '
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date / 2/ B SS(")
Refund Processed: Date /1/' /2.i.i By.C7 Invoice Processed: Date By
Permit Canceled: Date / .11/ ) ByVC Parcel Tag Added: Date By
l:\Building\Forms\RegPermitAction_120518.doc
111
TIGARD
City of Tigard
December 22, 2020
EC Company
PO Box 10286
Portland, OR 97296
Re: Permit No. ELC2020-00370
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9095 SW Burnham St
Project Name: Tigard Universal Plaza
Job No.: N/A
Refund Method: ® Check#237548 in the amount of$66.48.
❑ Credit card "return"receipt in the amount of$
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 obtained a permit in error for the wrong
address and replaced with permit ELC2020-00373. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
0(2")
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 l c A K I) 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 EC Company DATE: 12/9/2020
TO:
PO Box 10286
Portland, OR 97296 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 430320 Case #: ELC2020-00370
Date: 07/22/2020 Address/Parcel: 9095 SW Burnham
Pay Method: CreditCard Project Name: Tigard Universal Plaza
EXPLANATION: Per applicant's request as obtained permit at wrong address, see ELC2020-00373.
Refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee 00iC"kt'' Example;.2300000-43104 $Amount
Electrical Permit Fee 220-0000-43103 $59.36
12%State Surcharge 100-0000-24001 7.12
TOTAL REFUND: $66.48
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff ` �,7,, ,
If under$12,500 Division Manager V. L. Ory b
If under$25,000 Department Manager
If under$100,000 City Manager
If over
$50,000 Local Contract Review Board
Case Refund Processed: Date: (f//.. 2.1 By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
1111 CITY OF TIGARD RECEIPT
it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TI GAR O
Project Name: 77861 Tigard Universal Plaza
Site Address: 9095 SW BURNHAM ST
Receipt Number: 435829 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00370 $-66.48
Total: $-66.48
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237548 DHOWSE 08/13/2021 $-66.48
Payor: EC Company
Total Payments: $-66.48
Balance Due: $66.48
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TICARD
Project Name: 77861 Tigard Universal Plaza
Site Address: 9095 SW BURNHAM ST
?/fit 6/ ✓ r
Receipt Number: 430320 - 07/22/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00370 Temp Services or Feeders-200 amps 220-0000-43103 $59.36
or less
ELC2020-00370 Branch Circuits w/Purchase Service or 220-0000-43103 $14.84
Feeder
ELC2020-00370 12%State Surcharge-Electrical 100-0000-24001 $8.90
Total: $83.10
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6604522 PUBLICUSER108 07/22/2020 $83.10
Payor:
Total Payments: $83.10
Balance Due: $0.00
Page 1 of 1