ADU2021-00016 V
City of Tigard
August 13, 2021
Scotia Western States Housing LLC
15110 SW Boones Ferry Rd,Ste 500
Lake Oswego, OR 97035
Re: Permit No. ADU2021-00016
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: 15754 SW 76'b Ave.
Project Name: Knauss Subdivision
Job No.:
Refund: ® Check#240255 in the amount of$50.00.
❑ Credit card "return"receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Refund duplicate address fee invoiced in error.
If you have any questions please contact me at 503.718.2430.
Sincerely,
"'d
Dianna Omelas
Building Division Services Coordinator
Enc.
r: B, � r„I,a� aBn /,�� ,ybg�CS���iregon 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: Scotia Western States Housing LLC DATE: 8/6/2021
15110 SW Boones Ferry Rd, Ste 500
Lake Oswego, OR 97035 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 434896 Case#: ADU2021-00016
Date: 6/17/2021 Address/Parcel: 15754 SW 761hAve
Pay Method: CreditCard Project Name: Knauss Subdivision
EXPLANATION: Refund duplicate address fee invoiced in error as 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 $50.00
TOTAL REFUND: $50.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager d�J
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: J 11 By:
I:\Building\Refunds\RefundRequest.doc z 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: Knauss Subdivision Lot 3
Site Address: 15754 SW 76TH AVE
Receipt Number: 435821 - 08/13/2021 �rK
CASE NO, FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ADU2021-00016 $-50.00
Total: $-50.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240255 DHOWSE 08/13/2021 $-50.00
Payor: Scotia Western States Housing LLC
Total Payments: $-50.00
Balance Due: $50.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
Project Name: Knauss Subdivision Lot 3
Site Address: 15754 SW 76TH AVE
V /L f �/s�✓
Receipt Number: 434896 - 06/17/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ADU2021-00016 Application Fee 100-0000-43116 $50.00
Total: $50.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 7891545 PUBLICUSERO 06117/2021 $50.00
Payor:
Total Payments: $50.00
Balance Due: $0.00
Page 1 of 1
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUN 2 2 2021
m
Request for Permit Action CITY OFTIGARD
BUILDING DIVISION
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 TigardBadingPerrnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) SC 0 Tl AV kl FS-r'Ef&tJ S H o LLS I N t-
Mailing Address:
City/State/Zip: Lkr-c- 0S W E6-d, 04, 9
Phone No.: sc),3 — `'(s(p -q3o 7
t1ri-&r EA-n/ p 'Af 45-1 L,t.
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
VOID PERMIT APPLICATION.
(R
ERMIT FEES (attach copy of original receipt and provide explanation below).
REFUND
FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 21 - 0 00 1 (p
Site Address or Parcel#: [ S 7 `Y S-tJ '7�"*-- "I�:-
Project Name:
Subdivision Name: Lot #: 3
r�uP4 CA--r-r
EXPLANATION: Y2-,c l> f}-1)vA5S T en,4-r c-� /}5 d-J
A-P?,., C4-r7v;7 rsE or— f6o , oy
Signature: D �°� Date: 61L.Z12.1
Print Name: /9r✓^�fi D/1-/✓�Zs
Refund Policy
1. The city's Community Development Director,Building Official or 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 expended.
• 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.
FOR OFFICE USE ONLY
Route to S s Admin: Date 13V Route to Records: Date By
Refund Processed: Date 4 Bx Invoice Processed: Date 13y
Pemvt Canceled: Date B Parcel Tag ridded: Date B
1:\Building\Forms\RegPerrnit.Ac6 m_12 18.doe