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Permit Support Document (2) p 1111 1111 TIGARD City of Tigard November 8, 2019 Advanced Electric Signs Inc Attn: Steve Slack 1550 Down River Dr Woodland,WA 98674 Re: Permit No. ELC2019-00590 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 9412 SW Washington Square Rd Project Name: Lunch Box Job No.: N/A Refund Method: ® Check#233817 in the amount of$60.78. ❑ Credit card"return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. 0 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, 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 i1111111 II 1 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: Advanced Electric Signs Inc DATE: 11/1/2019 1550 Down River Dr. Woodland, WA 98674 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 425647 Case#: ELC2019-00590 Date: 9/5/2019 Address/Parcel: 9412 SW Washington Square Rd Pay Method: CreditCard Project Name: Lunch Box 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 Fees 220-0000-43103 $54.27 12%State Surchage 100-0000-24001 6.51 TOTAL REFUND: $60.78 APPROVALS: SIGNATU DATE: If under$5,000 Professional Staff 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: p/7/4/ By: 494 I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T I G.A R D Project Name: Lunch Box Site Address: 9412 SW WASHINGTON SQUARE RD K10 A AiA Receipt Number: 436188 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00590 $-60.78 Total: $-60.78 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 233817 DHOWSE 09/03/2021 $-60.78 Payor: Advanced Electric Signs Inc Total Payments: $-60.78 Balance Due: $60.78 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TEG1lR. Project Name: Lunch Box Site Address: 9412 SW WASHINGTON SQUARE RD K10 &-/C-/Arm"z. Receipt Number: 425647 - 09/05/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00590 Sign or Outline Lighting 220-0000-43103 $67.84 ELC2019-00590 12% State Surcharge-Electrical 100-0000-24001 $8.14 Total: $75.98 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 5525473 PUBLICUSER311 09/05/2019 $75.98 Payor: Total Payments: $75.98 Balance Due: $0.00 Page 1 of 1 • Order Receipt 5525473 Subject:Order Receipt 5525473 From:PayGov<no-reply@paygov.us> Date:9/5/2019, 10:32 AM To:info@advancedelectricsign.com iP,a yao v US This email is a confirmation of your Online Payment for PERMIT CENTER Cardholder Name:Susan Slack Telephone::(360)225-6826 Credit Card Type :Visa Last 4 digits:4XXX XXXX XXXX 8865 Confirmation Number:5525473 Card Auth Code:005796 Transaction ID: 1584049666 Agency Payment Amount:$75.98 Convenience Fee :$2.28 .. Total Amount Charged :$78.26 -""—"— First Name:Steve Last Name:Slack 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 PayGOV.US and will reflect"Convenience Fee"on your statement. For questions or concerns contact PayGOV.US at 1-866-480-8552.Transaction disputes will result in a$40 charge to the cardholder. 1 of 1 9/5/2019, 10:43 AM