Permit Support Document IN a
TIGARD
City of Tigard
September 10,2021
The Clean Air Act Inc.
15682 S Carus Rd
Beavercreek, OR 97004
Re: Permit No. MEC2021-00470
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11770 SW Aspen Ridge Dr
Project Name: Winter
Job No.: N/A
Refund Method: ® Check#240520 in the amount of$80.64.
❑ Credit card "return"receipt in the amount of$
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,
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
IIII " 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: The Clean Air Act Inc DATE: 9/6/2021
15682 S Cams Rd
Beavercreek, OR 97004 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 435096 Case#: MEC2021-00470
Date: 7/1/2021 Address/Parcel: 11770 SW Aspen Ridge Dr
Pay Method: CreditCard Project Name: Winter
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION; _.
Fee Description From Receipt I Revenue Account No. 1 Refund
Example Building Permit Fee Example: 2300000-43104 $Amount
Mechanical Permit Fee 230-0000-43102 $72.00
12°A)State Surchage 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager y) ��s 4....._
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYS 'EM;ADMINISTRATION USE ONLY
Case Refund Processed: Date: 9/lti/ -, By: r
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
IIIN . ... .
CITY OF TIGARD* ': 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
RECEIPT
Project Name: Installation �
Site Address: 11770 SW ASPEN RIDGE DR /1 "F
Lt A
Receipt Number: 436376 - 09/10/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2021-00470 $-80.64
Total: $-80.64
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240520 DHOWSE 09/10/2021 $-80.64
Payor: The Clean Air Act Inc.
Total Payments: $-80.64
Balance Due: $80.64
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71 CITY OF TIGARD RECEIPT
IE' 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
A T1 13
Project Name: Installation
Site Address: 11770 SW ASPEN RIDGE DR
Receipt Number: 435096 - 07/01/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2021-00470 Air Conditioning 230-0000-43102 $46.75
MEC2021-00470 12%State Surcharge-Mechanical 100-0000-24001 $10.80
MEC2021-00470 Minimum Fee Adjustment-Mechanical 230-0000-43102 $43.25
Total: $100.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7944326 PUBLICUSER115 07/01/2021 $100.80
Payor:
Total Payments: $100.80
Balance Due: $0.00
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