Permit Support Document INa
TIGARD
City of Tigard
April 3, 2020
JW Glisson Construction LLC
PO Box 1057
Gresham, OR 97030
Re: Permit No. MST2020-00080
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 8827 SW Thom St
Project Name: Thornwood Meadows,Lot 1
Job No.: N/A
Refund Method: ® Check#235136 in the amount of$750.00.
❑ Credit card "return" receipt in the amount of$
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 purchase did not go through and permit was
cancelled. Refund 100% of application fee.
If you have any questions please contact me at 503.718.2430.
Sincerely,
.414/./ki-Xj:( 4"")
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
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 TO: JW Glisson Construction LLC DATE: 3/20/2020
PO Box 1057
Gresham, OR 97030 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 428502 Case#: MST2020-00080
Date: 3/5/2020 Address/Parcel: 8827 SW Thorn St
Pay Method: CreditCard Project Name: Thornwood Meadows,Lot 1
EXPLANATION: Per applicant's request as purchase did not go through;refund 100%of submittal fee as
plan review was not completed.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plan Review 230-0000-43106 $750.00
TOTAL REFUND: $750.00
APPROVALS: SIGNA ES/DATE:
If under$5,000 Professional Staff A!/2-fj,-(�„-
If under$12,500 Division Manager (1`
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTE
M ADMINISTRATION USE ONLY
Case Refund Processed: Date: i� By -' 0
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
q
CITY OF TIGARD RECEIPT
131251 SW Hat Blvd.,Tigard OR 97223
I
503.639.4171
TtGARD
Project Name: Thornwood Meadows, Lot 1
Site Address: 8827 SW THORN ST
Receipt Number: 436228 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2020-00080 $-750.00
Total: $-750.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 235136 DHOWSE 09/03/2021 $-750.00
Payor: JW Glisson Construction LLC
Total Payments: $-750.00
Balance Due: $751.34
Page 1 of 1
III CITY OF TIGARD RECEIPT
s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TI All
Project Name: Thornwood Meadows, Lot 1
Site Address: 8827 SW THORN ST ®,t- c (ti/,9 Zj
Receipt Number: 428502 - 03/05/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MST2020-00080 Plan Review 230-0000-43106 $750.00
Total: $750.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6139043 DHOWSE 03/05/2020 $750.00
Payor: Jack Glisson,
Total Payments: $750.00
Balance Due: $1.34
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