SDR2021-00004 TIGARD
City of Tigard
October 3,2021
G&G Interiors LLC
PO Box 1344
Lake Oswego, OR 97035
Re: Permit No. SDR2021-00004
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12160 SW Grant Ave
Project Name: G&G Interiors LLC
Job No.: N/A
Refund Method: ® Check#2Y0439in the amount of$5,204.80.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as project costs to high to take on at this time.
Dedication,street and sidewalk costs push project over budget. Refund 80%of application
fees per planning as review was already completed prior to request to void permit.
If you have any questions please contact me at 503.718.2430.
Sincerely, 6)4 Q
"<'1Pt7c1
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
. City of Tigard
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 forPermitAction 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: G&G Interiors LLC DATE: September 20,2021
PO Box 1344
Lake Oswego,OR 97035 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 434729 Case#: SDR2021-00004
Date: 6/7/2021 Address/Parcel: 12160 SW Grant Ave
Pay Method: CreditCard Project Name: G&G Interiors
EXPLANATION: Per applicant's request to cancel project due to high costs. Refund 80%of application
fees per Agnes Lindor.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Application Fee 100-0000-43116 $5,204.80
TOTAL REFUND: $5,204.80
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff _ 7
If under$12,500 Division Manager D. L. Owned
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 T,ocal Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: /6/2 3/Z/ By: .C(761
I:\Building\Refunds\RefundRequest.da x 09/01/2010
ligCITY OF TIGARD RECEIPT
II 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T[G Ail D
Project Name: G&G Interiors
Site Address: 12160 SW GRANT AVE
Receipt Number: 437133 - 10/23/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SDR2021-00004 $-5,204.80
Total: $-5,204.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240637 DHOWSE 10/23/2021 $-5,204.80
Payor: G&G Interiors LLC
Total Payments: $-5,204.80
Balance Due: $5,204.80
Page 1 of 1
CITY OF TIGARD RECEIPT
i ! 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TrGARD
Project Name: G&G Interiors
Site Address: 12160 SW GRANT AVE d /6-7V A9 L
Receipt Number: 434729 - 06/07/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SDR2021-00004 Application Fee 100-0000-43116 $6,506.00
Total: $6,506.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7844926 PUBLICUSERO 06/07/2021 $6,506.00
Payor:
Total Payments: $6,506.00
Balance Due: $0.00
Page 1 of 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
i I i7 /
3 Request for Permit Action ,cad
TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223. 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPemuts®tigard-or.gov
FROM: g Owner ❑ Applicant ❑ Contractor El City Staff
Check("one
REFUND OR Name:
INVOICE TO: (avainee:ormaa;a°all G'R G 1/14i'ridr3 LL,C
Mailing Address: P d. (lox I3 Li c{
City/state/zip: L c L O5L, O /O re jon / 970,3.)
Phone No.: SC)3-c,cy - 0T70 (A !0I
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
CANCF.T/VOID PERMIT APPLICATION.►� REFUND PERMITr��FEES (attach copy of original receipt and provide explanation below).— c9/0
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: C&,, t-14 SDR toll - O000y <<tQ 1A21
Site Address or Parcel#: ( z 16 0 SU (-a 4- A
Project Name: G g Cr iqk.e.r i d rS
Subdivision Name: (IA k, Lot#: Oo 9 0C
EXPLANATION: Prc3 c{ CoSfS 0.r_ {a h j,1A + A-Nk cif" f ki.c
9co,,4;o1\ r 34r4-44 r .- S:�LI/0.tK c 4-Y park jcr ove.r
60 �4
Signature: � � � Date: 9- (5"20zi
Print Name: c c+e-t/L /1-/
Refund Policy
I. The city's Community Development Director,B"il.ling Official of 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 eapen•'d
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
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.,:
So6ri'z) ei' F-d % = 5.2orI. CO
,4r�„1/41- 30/ O
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date% y 3 Z/ B ./
Refund Processed: Date '/Zc/"2/ By t4't' Invoice Processed: Date By
Permit Canceled: Date / 'Zr. 2/ By.t('C Parcel Tag Added: Date By
t
I:\Building\Forms\RegPeroitAction..2051 dot