Permit Support Document VOID
fz /z RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT J JN 1 2020
aIN Re uest for Permit Action CITY OF TIGARD
BUILDING DIVISION
T t(:;A R t) 13125 SW Hall Blvd. •Tigard,Oregon 97223 . 503-718-2439•www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner [v�Applicant ['Contractor ❑ City Staff
Check(✓)one
INVOICEREFUN
OR Name:or Individual) C L am ly 1- i E.Q.6 ( (0 M Ht./-
Mailing TO: (Business
Mailing Address: )9 j 6 I VI:f t I. ICI
City/State/Zip: KT IZ I. I\/ 0 it °I RiO
PhoneNo.: SU) -3o4- 137u
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
E' CANCEL/VOID PERMIT APPLICATION.
aREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: IIII_C1020 —00156
Site Address or Parcel#: 7 l ( C 5 V S F io C r 51"
Project Name: co 1r�f
Subdivision Name: Lot#:
EXPLANATION: To 'LtAS CA NLC IrLf:1) Ri cc. I (NI' of--Far,
Y( \( coy L1) 13f-i‘l'
Signature: Date: 51.c,/2 O
Print Name: 2.A 1+ i-101.4
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. i : - f/` 2 2 o . ?3
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Route to Sys Admin Date By Route to Records: Date/d 7. Zi By 0
Refund Processed: Date ?/yz_i. Beo Invoice Processed: Date By
—
Permit Canceled: Date u� 20 B D Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 518. oc
III
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•
TIGARD
City of Tigard
October 3, 2021
Clean Energy Comfort
3816 River Rd N
Keizer, OR 97303
Re: Permit No. MEC2020-00156
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7115 SW Spruce St
Project Name: Coates
Job No.: N/A
Refund Method: ® Check#'iD6,2jin the amount of$91.09.
❑ Credit card "return" receipt in the amount of$
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
City of Tigard
r c n R n 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: Clean Energy Comfort DATE: September 20,2021
3816 River Rd N.
Keizer, OR 97303 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 428789 Case#: MEC2020-00156
Date: 3/23/2020 Address/Parcel: 7115 SW Spruce St
Pay Method: CreditCard Project Name: Coates
EXPLANATION: Per applicant's request as job was cancelled.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Mechanical Permit Fee 230-0000-43102 $81.33
12%State Surcharge 100-0000-24001 9.76
TOTAL REFUND: $91.09
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff �,, "
If under$12,500 Division Manager D. L. OVVI.e
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTE14*DMINISTRATION USE ONLY
Case Refund Processed: Date: j0A-3/2/ By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
III I` 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Ti(1 AR 1)
Project Name: Replacement /�
Site Address: 7115 SW SPRUCE ST CrG/h'�
Receipt Number: 437130 - 10/23/2021
CASE NO, FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M EC2020-00156 $-91.09
Total: $-91.09
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240621 DHOWSE 10/23/2021 $-91.09
Payor: Clean Energy Comfort
Total Payments: $-91.09
Balance Due: $91.09
Page 1 of 1
CITY OF TIGARD RECEIPT
■ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TtGARD
Project Name: Replacement
Site Address: 7115 SW SPRUCE ST ()f./ l/ fJ
Receipt Number: 428789 - 03/23/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2020-00156 Air Conditioning 230-0000-43102 $46.75
MEC2020-00156 Furnaces>= 100K BTU 230-0000-43102 $54.91
MEC2020-00156 12%State Surcharge-Mechanical 100-0000-24001 $12.20
Total: $113.86
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6210986 PUBLICUSER193 03/23/2020 $113.86
Payor:
Total Payments: $113.86
Balance Due: $0.00
Page 1 of 1