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ADJ2021-00004 V 0I City of Tigard * COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit .action 13125 SICK Hall Blvd. •Tigard,Oregon 97223. 503-718-2439•wvvvw.tigar_d-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-7i8-2439 Fra: 503-598-1960 TigardBuildingPermits@ igard-or90v FROM: ❑ Owner Dd Applicant El contractor Cl Citc Kra= 4'. li•pc<e. REFUND OR Name: N t Ci INVOICE TO. p3tisinmorindividuaIl Ad,, ,,, iailim Address: ��U l s v�-� S�y!54- .'t zZ city/state/zip: for 4 ct o P 7 -7 z-Ic7 Phone Nc.: Sb3.3'Ja . 2-615 PLEASE TAIL ACTION FOR THE ITEMS)CHECKED(✓I: ANCEL/VOID PERMIT APPLICATION. REFUND PERNIIT FEES(attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE(attach case fee schedule and pr de explanation below). Permit#: - �j AD 2 Z ,,j 1 ��? j1n Site Address or Parcel#: 3,S5 LI J 5 L"� (`'` D- ` V Project Name:c` ' Z J o2 U I Subdivision Name: t�/'A Lot#l: EXPLANATION: / "�o -�t� P -�' hoi rte;.; y GfNdD < LJ Signature: Date: ,2 Print N e: Refrand Pau:, I. The crWs Comma nn ticvck proem Ihrectoc,Budding c)ffical or City i✓ngiocetr any autbowe the reftmd of • Any fee which was erroneously paid or collected • Not more than 801/6 of the application or plan review fee when an application is withdrawn or canceled before review effort has been mpended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. `x ;%8 refinds will be retuned to the o ie,icnl payer in the hoist of a check ria LOS postal service. 3 P➢wr:allow 3-4 weeks far pnxxmmg refund mquemsL Route to Sys Admin. Dale By Route to Records: I Date Br Refinxl Processed_ Date / / y/ By Invoice Processed: I Date Br Penmit Canceled I Date By Parcel Tag Added Date R" L-\Bu3clinlrP'onus\ItegPe®icAction_I -1tY.8c- Z 11/19/21 City of Tigard Adamson Holdings,LLC 1509 SW Sunset Blvd, Suite 2B Portland, OR 97239 Re:Permit No. ADJ2021-00004 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 open space requirment is not required. Refund 100% of application fee. If you have any questions,please contact me at 503.718.2470. Sincerely, `I v 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 1 i ' 1 11/19/21 City of Tigard Adamson Holdings,LLC 1509 SW Sunset Blvd, Suite 2B Portland, OR 97239 Re: Permit No. ADJ2021-00004 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 open space 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 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#: 432667 Case#: ADJ2021-00004 Date: 1/27/2021 Address/Parcel: 9355 SW Hall Blvd Pay Method: Check Project Name: Cedarbrook Assisted Living EXPLANATION: Adjustment to reduce open space requirement is not required. Refund 100%of application fee. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 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 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: Bv: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 I 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: 437657 - 11/19/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ADJ2021-00004 $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 IoCITY OF TIGARD RECEIPT n 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Cedarbrook Assisted Living Site Address: 9355 SW Hall �� "lAj ef� Receipt Number: 432667 - 01/27/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ADJ2021-00004 Application Fee 100-0000-43116 $410.00 Total: $410.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 7295622 PUBLICUSERO 01/27/2021 $410.00 Payor: Total Payments: $410.00 Balance Due: $0.00 Page 1 of 1 I Dianna Ornelas 14,16--J "ao-�0 0 9 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 j 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 may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E.mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule." 1