ADJ2021-00003 c. VV 0
City of Tigard COMMUNITY DEVELOPMENT DrPART'AENT %///�//`�
Request for Permit Action
13125 SW, Hall Bled. •Tigard,Oregon 97223. 503-718-2439•www.tigard—o
TO: CITY OF TIGARD
Building Division
13125 SW Haff Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fag: 503-598-1960 TigardBuildingPermits@tigard-or goF-
FROM: ❑ Owner Applicant ❑ Contractor D Cita Sta7
cbeck N"p ac.
REFUND OR Name: r'y�
INVOICE TO: t at �aWn �Jc.,
Mailing Address: 15-J1 5-,n 5.
City/State/Zip: for 4'1c., 9- "l -7
Phone Nc.: Sz3.3 3o . -Z-6/5-
PLEASE
Z-6/SPLEASE TAKE ACTION FOR THE ITEM(S)CHECKED(✓):
X.RX 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 p de explanation below).
Permit#: - X AD 2 2
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Site Address or Parcel#: S� �l/5 5� 1��11 D-' U 4
Project Name: e lJ�` ' /9-,6J o2ya� " 3
Subdivision Name: Lot#:
EXPLANATION: c� �l r fiR-�--e t� e -e o�LAc
Signature: Date: ,2
Print
R fund Par;
i- 11w atty s Coimmuoitg Devekimueot Dir�Buldmg C)ffiai d or City ringweer mac audmMme 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
t , rrfiw&will be returned To the original payer in the form of a check ria US postal service.
3. Phase Am 3-4 wacks for Processmg w1und mquesm
Route to Sys Admin_ Date By Route to Records: Date By
Refund Processed_ Date// / y B Invoice Processed: Date Br
Permit C-WWXlerrl- Due / y Bt Pavcd T .added Date R..
1:\PAnMmg\Foffm\ltegPenntLkcuon_1l8 -
City of Tigard
11/19/21
Adamson Holdings,LLC
1509 SW Sunset Blvd, Suite 2B
Portland, OR 97239
Re: Permit No.ADJ2021-00003
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address or Parcel No.: 9355 SW Hall Blvd
Project Name: Ceaderbrook Assisted Living
Refund Check: #241311 in the amount of$410.00.
Comment(s): Adjustment to reduce bike parking requirment is not required. Refund
100% of application 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. 9 Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 9 www.tigard-or.gov
City of Tigard
11/19/21
Adamson Holdings,LLC
1509 SW Sunset Blvd, Suite 2B
Portland, OR 97239
Re: Permit No. ADJ2021-00003
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address or Parcel No.: 9355 SW Hall Blvd
Project Name: Ceaderbrook Assisted Living
Refund Check: #241311 in the amount of$410.00.
Comment(s): Adjustment to reduce bike parking requirment is not required. Refund
100%of application 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 0 www.tigard-or.gov
s
" City of 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: Adamson Holdings,LLC DATE: 11/14/2021
1509 SW Sunset Blvd, Suite 2B
Portland, OR 97239 REQUESTED BY: Dianna Ornelas
AL
TRANSACTION INFORMATION:
Receipt#: 432666 Case#: ADJ2021-00003
Date: 1/27/2021 Address/Parcel: 9355 SW Hall Blvd
Pay Method: Check Project Name: Cedarbrook Assisted Living
EXPLANATION: Adjustment to reduce bike parking requirement is not required. Refund 100% of
application fee.
REFUND INFORMATIONc
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Exarn le: 2300000-43104 $Amount
Application Fee 100-0000-43116 $410.00
TOTAL REFUND: $410.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager dC�
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
E FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: J I By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: Cedarbrook Assisted Living
Site Address: 9355 SW Hall
Receipt Number: 437656 - 11/19/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ADJ2021-00003 $410.00
Total: $410.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 241311 HVANDEWEGE 11/19/2021 $410.00
Payor: Adamson Holdings, LLC
Total Payments: $410.00
Balance Due: $410.00
Page 1 of 1
CITY OF TIGARD RECEIPT
■ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: Cedarbrook Assisted Living
Site Address: 9355 SW Hall
Receipt Number: 432666 - 01/27/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ADJ2021-00003 Application Fee 100-0000-43116 $410.00
Total: $410.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 7295597 PUBLICUSERO 01/27/2021 $410.00
Payor:
Total Payments: $410.00
Balance Due: $0.00
Page 1 of 1
Dianna Ornelas �6 0 Q Q
From: Agnes Lindor
Sent: Monday, October 25, 2021 7:31 AM
To: Dianna Ornelas
Subject: RE: Cedarbrook Assisted Living - 9355 SW Hall Blvd - Refund ADJ2021-00002, 3 &4
Hi Dianna-
100%-they were not required. Thanks!
Agnes
_. _ _.... _- .. ... .,..�...............
_.._ ._. _......
.......
.._ .
_. . ._
From: Dianna Ornelas<Dianna@tigard-or.gov>
Sent:Saturday, October 23, 20214:38 PM
To:Agnes Lindor<agnesl@tigard-or.gov>
Subject: Cedarbrook Assisted Living-9355 SW Hall Blvd - Refund ADJ2021-00002, 3 &4
Hi Agnes,
I'm processing refunds and there is a request to cancel and refund all three ADJs for this project (see attached file).
Please let me know what the percentage of refund we should allow, 80%or 100%.
Thanks.
Dianna L. Ornelas
Building Division Services Supervisor
City of Tigard I Community Development
13125 SW Hall Blvd I Tigard, OR 97223
503-718-2430 Direct 1503-718-2439 Permits
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
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