Permit Support Document V
TIGARD
City of Tigard
January 28,2020
Lin R Rogers Electrical Contractors Inc.
2050 Marconi Dr.
Alpharetta, GA 30005
Re: Permit No. ELC2019-00539
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9402 SW Washington Square Rd
Project Name: Dicks Sporting Goods
Job No.: N/A
Refund Method: ® Check#234476 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 job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4?(76-z`j-7—<--
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
u City of Tigard
i I G }z 1� 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: Lin R Rogers Electrical Contractors DATE: 1/17/2020
Inc.
2050 Marconi Dr,&ite266—
Alpharetta, GA 30005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 425254 Case#: ELC2019-00539
Date: 8/13/2019 Address/Parcel: 9402 SW Washingon Square
Pay Method: CreditCard Project Name: Dicks Sporting Goods
EXPLANATION: Per applicant's request as job was cancelled. 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: $5
APPROVALS: SIGNA D TE: `�_5B,Sr3
If under$5,000 Professional Staff i'�Q
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: 9/3/7f By: (")
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
INI 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Dicks Sporting Goods Fitting Room Refresh �� �
Site Address: 9402 SW WASHINGTON SQUARE RD P01 i2�,-7�t %J J
Receipt Number: 436203 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00539 $-50.33
Total: $-50.33
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 234476 DHOWSE 09/03/2021 $-50.33
Payor: Lin R Rogers Electrical Contractors
Total Payments: $-50.33
Balance Due: $50.33
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ft CITY OF TIGARD RECEIPT
IR
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T fGARD
Project Name: Dicks Sporting Goods Fitting Room Refresh
Site Address: 9402 SW WASHINGTON SQUARE RD P01 OM c ,' ,/ —i �,
Receipt Number: 425254 - 08/13/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00539 Branch Circuits wo/Purchase Service or 220-0000-43103 fe %I $56.18 e
Feeder
ELC2019-00539 12% State Surcharge-Electrical 100-0000-24001 (1-0 $6.74�
Total: $62.92
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5443319 PUBLICUSER999 08/13/2019 $62.92
Payor:
Total Payments: $62.92
Balance Due: $0.00
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