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Permit Support Document 1,1 a TIGARD City of Tigard June 24, 2019 Nordisk Systems, Inc. PO Box 822403 Vancouver,WA 98682 Re: Permit No. ELR2019-00067 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 15895 SW 72'Ave, #200 Project Name: Davis Dental Lab Job No.: N/A Refund Method: ® Check#232422 in the amount of$134.40. ❑ Credit card "return" receipt in the amount of$ 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 permit was taken out for the wrong address. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov u 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 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: Nordisk Systems, Inc. DATE: 6/17/2019 PO Box 822403 Vancouver, WA 98682 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 422683 Case#: ELR2019-00067 Date: 4/11/2019 Address/Parcel: 15895 SW 72nd Ave,#200 Pay Method: CreditCard Project Name: Davis Dental Lab EXPLANATION: Per applicant's request as permit was taken out for the wrong address. Refund 80%of permit fees. REFUND INFORMATION: Fee Descriptionp From Receipt Revenue Account No. Refund Example:;Building Permit Fee e x --,,:` Example: 2300000-43104 $Amount Electrical Permit 220-0000-43103 $120.00 12%State Surcharge 100-0000-24001 14.40 TOTAL REFUND: $134.40 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff ` 7,4r- _ 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: 5,%G/f Z7' By: ,,,/, I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 4 i is 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Davis Dental LAb Site Address: 15895 SW 72ND AVE 200 Receipt Number: 434447 - 05/21/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELR2019-00067 $-134.40 Total: $-134.40 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 232422 DHOWSE 05/21/2021 $-134.40 Payor: Nordisk Systems, Inc. Total Payments: $-134.40 Balance Due: $0.00 Panes 1 of 1 U CITY OF TIGARD RECEIPT a- • 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Davis Dental LAP Site Address: 15895 SW 72ND AVE 200 Receipt Number: 422683 - 04/11/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELR2019-00067 Restricted Energy Permit 220-0000-43103 $150.00 ELR2019-00067 12%State Surcharge-Electrical 100-0000-24001 $18.00 Total: $168.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 09574G PUBLICUSER111 04/11/2019 $168.00 Payor: Scott C Thompson Total Payments: $168.00 Balance Due: $0.00 Page 1 of 1 To: '15035981960 From: Veronica Orazio 4-23-19 12:48pm p. 2 of 3 RECEIVED City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT APR 2 3 2019 IN ..r CITY OF TIGARD Request for Permit Action BUILDING DIVISION TIGARD 13125 SW Hall Blvd. •Tigard, Orcgon 97223. 503-718-2439 •www.tigard-or.gov TO: CITY OF TIGARD Building Division ‘ 101 D 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits(a tigard-or.gov(p,�/? AW FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff Check(/)one REFUND OR Name: INVOICE TO: (l3usiness or Individual) Nordisk Systems,Inc. Mailing Address: PO Box 822403 City/State/Zip: Vancouver,WA 98682 Phone No.: 503-252-1462 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(✓): EX CANCEL/VOID PERMIT APPLICATION. X REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: ELR2019-00067 Site Address or Parcel#: 15350 SW Sequoia Parkway,Sntie 300 Project Name: navis Dental Lab Subdivision Name: Fanno Creek Lot#: 40 EXPLANATION: Wrong address provided by on site tech �i9i:d vV 9nca1 oVvaw.:.ttuu Veronica Orazio 'rr�'<',,�a�„�..,,m Date: 4/23/19 Signature: N x:,�.A0.�.�o,>; Print Name: Veronica K Orazio 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 fcc for issued permits prior to any inspection requests. 2. All refunds will he returned to the original payer in the foam of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. /S o . Cr-0 /2 0 . C V 3 O e v / 6 if, cr-d /.' v• yv _3 3 . (0. a FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date S Z! By +� Refund Processed: Date40//V/9 BeyS// Invoice Processed: Date By- Permit Canceled: Date G 7//9, By 07. eel Tag Added: Date By 1:\1iui1ding\Ions\RegPermitAction_l 0i18.emoc To: '15035981960 From: Veronica Orazio 4-23-19 12:48pm p. 3 of 3 CITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT 8. COMMUNITY DEVELOPMENT Permit#: ELR2019-00067 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/11/2019 TIGARD g Parcel: 2S112DC00500 Jurisdiction: Tigard Site address: 15895 SW 72ND AVE 200 Project: Davis Dental LAb Subdivision: FANNO CREEK ACRE TRACTS Lot: 40 Project Description: Low Voltage Cabling Contractor: NORDISK SYSTEMS Owner: PACIFIC REALTY ASSOCIATES LP PO BOX 822403 ATTN:N PIVEN VANCOUVER,WA 98682 15350 SW SEQUOIA PKWY#300 PORTLAND,OR 97224 PHONE: 503-252-1462 PHONE: FAX: 503-252-2343 FEES Description Date Amount Specifics: Restricted Energy Permit 04/11/2019 $150.00 12%State Surcharge-Electrical 04/11/2019 $18.00 Type of Use: COM Class of Work: ADD Total Number of Systems: 2 Audio&Stereo: 0 Boiler Controls: 0 CCTV: 0 Clock Systems: 0 Data&Telecommunications: 1 Fire Alarm: 0 HVAC: 0 Instrumentation: 0 Intercom/Paging: 1 Landscape/Irrigation: 0 Landscape Lighting: 0 Medical: 0 Nurse Calls: 0 Protective Signal: 0 Security Alarm: 0 Other: 0 Total $168.00 Other Desc: Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: Permittee Signature: OWNER INSTALLATION ONLY The installation is being made on property I own which is not intended for sale,lease or rent. OWNER'S SIGNATURE: Date: CONTRACTOR INSTALLATION ONLY SIGNATURE OF SUPR.ELEC' Date: LICENSE NO. Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. To: '15035981960 From: Veronica Orazio 4-23-19 12:48pm p, 1 of 3 Fax Date: 4/23/2019 To: '15035981960 From: Veronica Orazio Subject: Permit Cancellation Please see the attached request to cancel our permit as it was pulled for the wrong location. Thank you, Veronica [NSI Logo 1] Veronica Orazio 1 Telecom Manager I NW ComTech, a Nordisk Company Portland: (503) 252-1462 I Vancouver: (360) 993-12341 Fax : (503) 252-2343 veronica©nordisksystems.com<mailto:veronica©nordisksystems.com> www.nordisksystems.com<http://www.nordisksystems.com/>