Permit Support Document•
•
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCT 721
III I CITY OF TIGARD
Request for Permit Action BUILDING DIVISION
TIGARD 13125 SW Half Blvd. •Tigard,Oregon 97223• 503-718-2439• wvw.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 ❑ Applicant Contractor ❑ City Staff
Check(i)one /
REFUND OR Name:
INVOICE TO: (Business or Individual) .)
Mailing Address: PO E){,))< Gl(?)e
City/State/"lip: Dot‘\c S {`pc�91 1aiL-;
Phone No.: ‘.;:X.)"2 -- `7'iC 2.t +1
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#:
Site Address or Parcel #: 1`m oC•Dg./ I
Project Name: Dies en tfifn Y e Cei,r14 -1,A
Subdivision Name: Lot #:
EXPLANATION: Pk I(lo-d AgQ c n of x—
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Signature: ' zi,L UX:it:a eit,-(f f,k; ti'i Date: ( Z� 2
Print Name: C�
Refund Poli S
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. /or '`f•,
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. r
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date By
Refund Processed: Date '7 *f2/ ByA0O Invoice Processed: Date By
Permit Canceled: Date Baa Parcel Tag Added: Date By
1:\Building\forms\RegPermitAction_12(518.cfoc
/2(J j2 c. %LG 6,/-"/ 4 /O/2/
111 n
TIGARD
City of Tigard
11/19/21
Protech Power
PO Box 988
Dallas, OR 97338
Re: Permit No. ELC2021-00611
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address or Parcel No.: 9925 SW Greenburg Rd
Project Name: Crescent Grove Cemetary
Refund Check: #241308 in the amount of$482.00.
Comment(s): Per applicant request as duplicate permit (see ELC2020-00547). Refund
100% of permit fee
If you have any questions,please contact me at 503.718.2470.
Sincerely,
Holly Van De Wege
Program Development Specialist
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
INq
TIGARD
City of Tigard
11/19/21
Protech Power
PO Box 988
Dallas, OR 97338
Re: Permit No. ELC2021-00611
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address or Parcel No.: 9925 SW Greenburg Rd
Project Name: Crescent Grove Cemetary
Refund Check: #241308 in the amount of$482.00.
Comment(s): Per applicant request as duplicate permit (see ELC2020-00547). Refund
100%of permit fee
If you have any questions,please contact me at 503.718.2470.
Sincerely,
Holly Van De Wege
Program Development Specialist
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
'PI
_ " City of Tigard
T n K 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: Protech Power DATE: 11/14/2021
PO Box 988
Dallas, OR 97338 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 437120 Case#: ELC2021-00611
Date: 10/22/2021 Address/Parcel: 9925 SW Greenburg Rd
Pay Method: CreditCard Project Name: Crescent Grove Cemetary
EXPLANATION: Per applicant request as duplicate permit(see ELC2020-00547). Refund 100% of
permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $430.36
12%State Surcharge 100-0000-24001 51.64
TOTAL REFUND: $482.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager �61.5 . r 42.-4.--"
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: By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
IICITY OF TIGARD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: SLENNING V eC�
Site Address: 9555 SW SHADY PL �C
Receipt Number: 437660 - 11/19/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2021-00834 $-80.64
Total: $-80.64
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 241337 HVANDEWEGE 11/19/2021 $-80.64
Payor: Heat Relief Heating& Cooling
Total Payments: $-80.64
Balance Due: $80.64
Page 1 of 1
INCITY OF TIGARD RECEIPT
s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIC:;ATID
Project Name: Crescent Grove Cemetary
Site Address: 9925 SW GREENBURG RD D4/ `/A/
Receipt Number: 437120 - 10/22/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2021-00611 Services or Feeders-201 to 400 amps 220-0000-43103 $133.56
ELC2021-00611 Branch Circuits w/Purchase Service or 220-0000-43103 $296.80
Feeder
ELC2021-00611 12% State Surcharge-Electrical 100-0000-24001 $51.64
Total: $482.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 8431837 PUBLICUSER123 10/22/2021 $482.00
Payor:
Total Payments: $482.00
Balance Due: $0.00
Page 1 of 1