The URL can be used to link to this page

Permit Support Document RECEIVED OCT 2 7 2021 1,111City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Gil'(OF TIGARD _ Request for Permit Action BUILDING DMS)ON T I t;A R t) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division V1 D 13125 SW Hall Blvd.,Tigard,OR 97223 /r - /y 'vZ/ 4 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) .-oii)Pe ' 1, tv,{t S t\tc...\-yi G Mailing Address: ' V 1 fo%4\(Ma Ok tiE sic G City/State/Zip: �o,Lt$,N1, CA_ ok hot Phone No.: D1)-C\<6 6 ‘1 \ PLE SE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit #: E`C. 202..\ — OO --No Site Address or Parcel#: I,Sa„2, 00101,200 Project Name: V i\LIG-i 1j2_S Subdivision Name: \ ^ `Lot #: EXPLANATION: CAA.CAp'(`AQV O C Qo ce l\P t 1 yiso -TV\e oa k\mt W S1fk aide eA o f P-Dv W 0Y k - Signature: Date: 10`t`1'2 I Print Name: AV(Aa` (Ant 4 t,✓ Refund Policy 1. The city's Communinv Development Director,Building Official or City Engineer may authorize the refund of • Any fee which was erroneously paid or collected. • Not more than 80`ih of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 804;,of the application or permit fee for issued permits prior to any inspect}p requests. 2�j'I?q/.1/ 2. All refunds will be returned to the original paver in the form of a check via US postal service. ��Ce--�� w� 3. Please allow 3-4 weeks for processing refund requests. ,E-M17- / 'o, 70 - tea,s'O = Ao• I'y /Z04 a C/t /Z. of - 9,6,6 -'•y-- / mot/r /SScc EZ /I 2. '71' ' p• .?2 a.2 — 4' FOR OFFICE USE ONLY Route to Sys,Amin: Date / By all Route to Records: Date k% Tri •(,I B- ,•- Refund Processed: Date// / ?>i By 1eta Invoice Processed: Date By' i Permit Canceled: Date /, s.//y/ By4 c) Parcel Tag Added: Date By 1:\Building\Forms\RryPermitActiun_l 51$.duc 11111 CITY OF TIGARD RECEIPT a , 13125 SW Hall Blvd,Tigard OR 97223 503.639.4171 TIC;A111) Project Name: Vikki BRS Site Address: 11405 SW 95TH AVE Receipt Number: 436902 - 10/08/2021 CASE NO, FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2021-00570 12%State Surcharge-Electrical 100-0000-24001 $12.08 ELC2021-00570 Services or Feeders-200 amps or less 220-0000-43103 $100.70 Total: $112.78 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 8373349 PUBLICUSER39145110/08/2021 $112.78 Payor: KopperWorksElect Total Payments: $112.78 Balance Due: $0.00 Page 1 of 1 V TIGARD City of Tigard 11/19/21 Kopper Works Electric 3772 Portland Rd NE, Ste C Salem, OR 97301 Re: Permit No. ELC2021-00570 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.: 11405 SW 95th Ave Project Name: Vikki BRS Refund Check: #241339 in the amount of$90.22. Comment(s): Per applicat request as customer cancelled job. Refund 80% of permit fees. If you have any questions,please contact me at 503.718.2470. Sincerely, )0\kir 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 N City of Tigard T(G A RD 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: Kopper Works Electric DATE: 11/14/2021 3772 Portland Rd NE, Ste C Salem, OR 97301 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 436902 Case#: ELC2021-00570 Date: 10/8/2021 Address/Parcel: 11405 SW 95th Ave Pay Method: CreditCard Project Name: Vikki BRS EXPLANATION: Per applicant request as customer cancelled job. Refund 80% 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 $80.56 12%State Surcharge 100-0000-24001 9.66 TOTAL REFUND: $90.22 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff � ) ^ If under$12,500 Division Manager If under$25,000 Department Manager �Y If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE`ONLY Case Refund Processed: Date: h11\A1 Z '_L� �__....__ LB u I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARDII RECEIPT i s 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD, t --- 'C\")(4) Project Name: Vikki BRS \Re Site Address: 11405 SW 95TH AVE Receipt Number: 437658 - 11/19/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID E LC2021-00570 $-90.22 Total: $-90.22 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 241339 HVANDEWEGE 11/19/2021 $-90.22 Payor: Kopper Works Electric Total Payments: $-90.22 Balance Due: $90.22 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T€CARD Project Name: Vikki BRS Site Address: 11405 SW 95TH AVE Qg/6/N4/, Receipt Number: 436902 - 10/08/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2021-00570 Services or Feeders-200 amps or less 220-0000-43103 $100.70 ELC2021-00570 12%State Surcharge-Electrical 100-0000-24001 $12.08 Total: $112.78 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 8373349 PUBLICUSER391 10/08/2021 $112.78 Payor: Total Payments: $112.78 Balance Due: $0.00 Page 1 of 1 Julie Drinkwater From: Service@kopperworkselectric.com Sent: Wednesday, October 27, 2021 12:04 PM To: #Building Permit Technicians Subject: Permit Refund Request Attachments: Permit Refund Request.pdf Categories: Julie You don't often get email from service@kopperworkselectric.com. Learn why this is important Warning!This message was sent from outside your organization and we are unable to verify the sender. Hello, Attached is our refund/cancellation request for an electrical permit. The customer cancelled the day of. Please let me know if there is anything additional that is needed. Thanks! Abigail Ledbetter Service Department Coordinator Ix o. 503.486.7171 I a. 3772 Portland Rd Ne Ste. C Salem, Oregon 97301 service©kopperworkselectric.com kopperworkselectric.com U 1