Permit Support Document (2) IN NI
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TIGARD
City of Tigard
October 11, 2019
3 Mountains Plumbing
5304 N Albina Ave
Portland, OR 97217
Re: Permit No. PLM2019-00341
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12180 SW Katherine St
Project Name: Sui
Job No.: N/A
Refund Method: ® Check#233524 in the amount of$64.96.
❑ Credit card"return"receipt in the amount of$ .
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 to void permit as it was a duplicate permit.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Since ely,
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
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: 3 Mountains Plumbing DATE: 10/4/2019
5304 N Albina Ave
Portland, OR 9-7A t 7 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 425429 Case#: PLM2019-00341
Date: 8/23/2019 Address/Parcel: 12180 SW Katherine St
Pay Method: CreditCard Project Name: Sui
EXPLANATION: Per applicant's request as they obtained duplicate permits for same work. Refund 80%
of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit Fee 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNAT ES/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 ACCELA4SYfritlit,ADMINIStRATION USE`ONLY
Case Refund Processed: Date: F/. 741-( By: 47 a
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
111 CITY OF TIGARD RECEIPT
■ • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T I G AR 1)
Project Name: Sui
Site Address: 12180 SW KATHERINE ST6—AuA/6
Receipt Number: 436098 - 08/27/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2019-00341 $-64.96
Total: $-64.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 233524 DHOWSE 08/27/2021 $-64.96
Payor: 3 Mountains Plumbing
Total Payments: $-64.96
Balance Due: $64.96
Pang+ 1 of 1
11111 CITY OF TIGARD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
- - 503.639.4171
T f i;A 1 1)
Project Name: Sui
Site Address: 12180 SW KATHERINE ST
Receipt Number: 425429 - 08/23/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2019-00341 Storm Sewer 230-0000-43101 $62.54
PLM2019-00341 12%State Surcharge-Plumbing 100-0000-24001 $8.70
PLM2019-00341 Minimum Fee Adjustment-Plumbing 230-0000-43101 $9.96
Total: $81.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5481820 PUBLICUSER107 08/23/2019 $81.20
Payor:
Total Payments: $81.20
Balance Due: $0.00
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