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ADJ2021-00002 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT l�/y�2/ •�Q�} Request for Permit Action 13125 SSV Hall Bled. •Tigard,Ore"9723. 503-718-2439•www tigard-or eov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPennits@ligard-orgov FROM: ❑ Owner Applicant ❑ Contractor D City Sta= Rxc$,:. tom. REFUND OR Name: i YI i INVOICE TO: aka"—or'-1"'aurl 4iailing Address: 15-241 2- City/State/Zip: -Pn('41..,4 -7 7-3j Phone Nc.: sb3,3-j t:) . -Z-615- PLEASE X15- PLEASE TAKE ACTION FOR THE ITEMS)CHECKED(1): CANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES(attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE(attach case fee schedule and pr vide explanation below). PermJit#: - ADJ 2 2 ,J �? h Site Address or Parcel#: 3�� 5� w �`- F> Ve U 94 Project Name: �1� dooa 02 r Subdivision Name: VAA Lot#: EXPLANATION: �� -el -ed t Signature: Date: x llWz Print N e: Refund Pcar I- 'nx oWs Cann n n ay Utvek pment Drtic m Bwkbng Cil or Cm f:agineer mac anhanve the refimd of • Any fee which was erroneously paid or collected • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 8016 of the application or permit fee for issued permits prior to any mspecmm requests. .\0 refimds will be re n ned to the ucWnA payer in the farm of a clrr k via US Postal Fervid 3 Please allow.14 weeks for procmimW rt$and axpitim Route to Sys Adnun Dare Br Route to Records: Date lir Refund Processed: Date I "'W24 Bc Invoice Processed: Date R� Permit Canceled Date B Parcd T 1: Dare R I-N%ad"gNForms\Regrem=Acuon_t is City of Tigard 11/19/21 Adamson Holdings,LLC 1509 SW Sunset Blvd, Suite 2B Portland, OR 97239 Re: Permit No. ADJ2021-00002 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 vehicular parking requirment is not required. Refund 100% of application fee. If you have any questions,please contact me at 503.718.2470. Sincerely, 4xo�—� 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 N • City of Tigard 11/19/21 Adamson Holdings,LLC 1509 SW Sunset Blvd, Suite 2B Portland, OR 97239 Re: Permit No. ADJ2021-00002 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 vehicular 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 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 RequestforPeimitAction 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#: 432665 Case#: ADJ2021-00002 Date: 1/27/2021 Address/Parcel: 9355 SW Hall Blvd Pay Method: Check Project Name: Cedarbrook Assisted Living EXPLANATION: Adjustment to reduce vehicular parking 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 Case Refund Processed: Date: kk 1 Ak Z\ B 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 e Site Address: 9355 SW Hall Receipt Number: 437655 - 11/19/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ADJ2021-00002 $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 8 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Cedarbrook Assisted Living Site Address: 9355 SW Hall j�A?� Receipt Number: 432665 - 01/27/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ADJ2021-00002 Application Fee 100-0000-43116 $410.00 Total: $410.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 7295584 PUBLICUSERO 01/27/2021 $410.00 Payor: Total Payments: $410.00 Balance Due: $0.00 Page 1 of 1 Dianna Ornelas (,,?,� 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 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