Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
• Request for Permit Action MAR s 2020
1 CITY OF TIGARD
.I..I t;,A It O 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-catitIC/ING DIVISION
TO: CITY OF TIGARD VOID
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 3 7/�
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits tigard-or.gov
FROM: ❑ Owner [ ,'Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: •
INVOICE TO: (Business or Individual) G L E
k art
Mailing Address: p.0• bOy, 102So
City/State/Zip: Pov-Hcod j 612 61-721t�
Phone No.: 503"'2.2•-S"' cD1$7
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
154 CANCFT /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#: EI.G2A?.�-Oo i 12-
Site Address or Parcel #: 9000 S VA1 b u Irh iris 12 d t T�a trd �)2 Q72-23
•
Project Name: T�! cl g r4- l J41Q?v1 my() schhol
Subdivision Name: Lot#:
EXPLANATION: PfJv 4- wits T ullet incorad
Signature: ('i • Date: /I V/ f[-t1 W
Print Name: net at I 1
Refund Policy
I. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Nor more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. ,/P — 9 t CI c li, 2-y
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FOR OFFICE USE ONI.A
Route to Sys Admin: Date By Route to Records: Date ?Ng./ By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 3 7/it) By .ice, arcel Tag Added: Date By
l:\Building\Forams\RecPermitAction_I14051oc
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TIGARD
City of Tigard
April 3,2020
E C Company
PO Box 10286
Portland, OR 97296
Re: Permit No. ELC2020-00112
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9000 SW Durham Rd
Project Name: Tigard High School
Job No.: N/A
Refund Method: ® Check#235113 in the amount of$50.33.
❑ Credit card"return"receipt in the amount of$
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 permit was obtained for the wrong scope of
work (see correct permit ELC2020-00115). 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
IIIII
ill
City of Tigard
T I G A R D 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: EC Electric DATE: 3/20/2020
PO Box 10286
Portland, OR 97296 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 428341 Case#: ELC2020-00112
Date: 2/25/2020 Address/Parcel: 9000 SW Durham Rd
Pay Method: CreditCard Project Name: Tigard High School
EXPLANATION: Per applicant's request as they obtained permit for the wrong scope of work. 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 220-0000-43103 $44.94
12%State Surcharge 100-0000-24001 5.39
TOTAL REFUND: $50.34' 3 3
APPROVALS: SIG ATURES/DATE:
If under$5,000 Professional Staff & .?-( 4-�
If under$12,500 Division Manager
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: f,X.3/7/ By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
IIi4
.. 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Tigard High School Theater
Site Address: 9000 SW DURHAM RD /f_,7.2..tiv(_‘.
Receipt Number: 436227 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00112 $-50.33
Total: $-50.33
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 235113 DHOWSE 09/03/2021 $-50.33
Payor: EC Electric
Total Payments: $-50.33
Balance Due: $50.33
Page 1 of 1
CITY OF TIGARD RECEIPT
- 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Tl „tIt1)
Project Name: Tigard High School Theater
Site Address: 9000 SW DURHAM RD a/4 i (ic71--(-g-
Receipt Number: 428341 - 02/25/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2020-00112 Branch Circuits wo/Purchase Service or 220-0000-43103 $56.18
Feeder
ELC2020-00112 12%State Surcharge- Electrical 100-0000-24001 $6.74
Total: $62.92
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6098620 PUBUCUSER10895IO2/25/2020 $62.92
Payor:eccompany
Total Payments: $62.92
Balance Due: $0.00
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