Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT SEP 1 5 2021
111 ft Ct gTY OF T IGARD
2 Request for Permit Action BUILDING DIVISION
T i t;A K I� 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-orov
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 ❑X Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) EC Company
Mailing Address: 2121 NW Thurman ST
City/State/Zip: Portland, OR 97210
Phone No.: 503.278.6851
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
0 •ID PERMIT APPLICATION.
REFUND ' IT FEES (attach copy of original receipt and provide explanation below).
•ICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ELC2021-00517
Site Address or Parcel#: 13125 SW Hall Blvd Tigard, OR 97223
Project Name: City of Tigard, Police Bureau Generator
Subdivision Name: Lot #:
EXPLANATION:
Accidentally marked needing 1 200A and 1 400A when I only needed the 400A.
I caught it on the review screen, and went back to fix it, but it didnt seem to click,
and I was charged'fo otf?,l would like to get a refund on the$100.70 200A.
Signature: Date: 9.15.21
Print Name: Eli Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. �/e,0 • 7 D
/ere '7o P!2 0lo 7d1/f Swdcet p g (vn/ /L D , 7 a)
Route to Sys Admin: Date B Route to Records: Date/ 2 3/2` By
Refund Processed: Date 9/2 /zi $sI Invoice Processed: Date ,/ By
Permit Canceled: Date A//,/I'- B}+ ' Parcel Tag Added: Date By
1:\Building\Forms\RegPermitAction_120518.doc f 7. by'
i
TIGARD
City of Tigard
October 3, 2021
EC Company
2121 NW Thurman St
Portland, OR 97210
Re: Permit No. ELC2021-00517
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 13125 SW Hall Blvd
Project Name: City of Tigard-PD
Job No.: N/A
Refund: ® Check#;yowin the amount of$112.78.
❑ Credit card "return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comments: Per applicant's request as they purchased the wrong electrical service online.
Refund 100% of permit fees paid.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Omelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
i
I
;i
r
IN .
a ■ City of Tigard
i
liwk
pi) Accela Refund Request
i
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: EC Company DATE: September 20,2021
2121 NW Thurman St
Portland,OR 97210 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 436453 Case#: FT C2021-00517
Date: 9/15/2021 Address/Parcel: 13125 SW Hall Blvd
Pay Method: CreditCard Project Name: City of Tigard-Police Dept.
i EXPLANATION: Per applicant's request as they selected the wrong electrical service item online;refund
100%of permit fees paid.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $100.70
12%State Surcharge 100-0000-24001 12.08
TOTAL REFUND: $112.78
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. (9P'vi..eZct.
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: /Q/z l/z/ By:
1:\Building\Refunds\RefundRequest.doc x 09/01/2010
ili
CITY OF TIGARD RECEIPT
1111 7 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T I C A R.D
Project Name: City of Tigard, Police Bureau Generator
Site Address: 13125 SW HALL BLVD
Receipt Number: 437134 - 10/23/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00517 $-112.78
Total: $-112.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240629 DHOWSE 10/23/2021 $-112.78
Payor: EC Company
Total Payments: $-112.78
Balance Due: $112.78
Page 1 of 1
CITY OF TIGARD RECEIPT
a ' 13125 SW Hall Blvd.,Tigard OR 97223
11
503.639.4171
TIGARD
Project Name: City of Tigard, Police Bureau Generator
Site Address: 13125 SW HALL BLVD 012/G LAJ,1_
Receipt Number: 436453 - 09/15/2021 O
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00517 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2021-00517 Services or Feeders-201 to 400 amps 220-0000-43103 $133.56
ELC2021-00517 Branch Circuits w/Purchase Service or 220-0000-43103 $14.84
Feeder
ELC2021-00517 12%State Surcharge-Electrical 100-0000-24001 $29.89
Total: $278.99
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 8275346 PUBLICUSER108 09/15/2021 $278.99
Payor:
Total Payments: $278.99
Balance Due: $0.00
11
I
Page 1 of 1
1
II CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: City of Tigard, Police Bureau Generator
Site Address: 13125 SW HALL BLVD
Receipt Number: 436453 - 09/15/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00517 Services or Feeders-201 to 400 amps 220-0000-43103 $133.56
ELC2021-00517 12%State Surcharge-Electrical 100-0000-24001 $29.89
ELC2021-00517 Services or Feeders-200 amps or less 220-0000-43103 $100.70
ELC2021-00517 Branch Circuits w/Purchase Service or 220-0000-43103 $14.84
Feeder
Total: $4
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 8275346 PUBLICUSER10895£09/15/2021 $278.99
Payor: eccompany
Total Payments: $278.99
Balance Due: $0.00
Page 1 of 1