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Permit Support Document IIIill TIGARD City of Tigard June 24,2019 Choung Ang 12070 SW 119th Ave Tigard, OR 97223 Re: Permit No. ELC2019-00268 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10080 SW Katherine St Project Name: Phou&Ang Job No.: N/A Refund Method: ® Check#232384 in the amount of$237.44. ❑ Credit card "return"receipt in the amount of$ . Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. 0 Trust account"deposit"receipt in the amount of$ . Comment(s): Electrical work added to existing permit (MST2019-00115) so a separate electrical permit was not required. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, .......a'5:::A7‘e--7-1-'---- 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 1111 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: Choung Ang DATE: 6/17/2019 12070 SW 119th Ave Tigard, OR 97223 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 423015 Case#: ELC2019-00268 Date: 4/24/2019 Address/Parcel: 10080 SW Katherine St Pay Method: CreditCard Project Name: Lynn&Ang EXPLANATION: Electrical should have been added to existing permit MST2019-00115 per Branden Taggart. Refund 100% of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example:-Building Permit Fee Example: 2300000-43104 $Amount , Electrical Permit 220-0000-43103 $212.00 12%State Surcharge 100-0000-24001 25.44 TOTAL REFUND: $237.44 APPROVALS: SIGNAT ES/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: ' Zoy,y By: -Cj` // I:\Building\Refunds\RefundRequest.doc x 09/01/2010 *, CITY OF TIGARD RECEIPT i 2 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: PHOU Site Address: 10080 SW KATHERINE ST Receipt Number: 423018 - 04/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00268 $-237.44 Total: $-237.44 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 32292D DHOWSE 04/24/2019 $-237.44 Payor: Choung Ang Total Payments: $-237.44 Balance Due: $0.00 Pang. 1 of 1 CITY OF TIGARD RECEIPT g• 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T f t A R D Project Name: PHOU Site Address: 10080 SW KATHERINE ST Receipt Number: 423015 - 04/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00268 Services or Feeders-200 amps or less 220-0000-43103 $100.70 ELC2019-00268 Branch Circuits w/Purchase Service or 220-0000-43103 $111.30 Feeder ELC2019-00268 12% State Surcharge- Electrical 100-0000-24001 $25.44 Total: $237.44 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 32292D BTAGGART 04/24/2019 $237.44 Payor: Choung Ang Total Payments: $237.44 Balance Due: $0.00 • Page 1 of 1 lIlIlCITY OF TIGARD RECEIPT i . 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TE ARO Project Name: PHOU Site Address: 10080 SW KATHERINE ST Receipt Number: 423015 - 04/24/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2019-00268 Services or Feeders-200 amps or less 220-0000-43103 $100.70 ELC2019-00268 Branch Circuits w/Purchase Service or 220-0000-43103 $111.30 Feeder ELC2019-00268 12% State Surcharge- Electrical 100-0000-24001 $25.44 Total: $237.44 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 32292D BTAGGART 04/24/2019 $237.44 Payor: Choung Ang Total Payments: $237.44 Balance Due: $0.00 Page 1 of 1 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN 0 D N Request for Permit Action 7//q - T i 6 A R C) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): E CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit #: ,. d/1--0g Site Address or Parcel#: /0c)$"d ski ke% i,11/4,t 551-, Project Name: NHe Subdivision Name: Lot #: EXPLANATION: 4.4S Yerri- 4y, y/ 6 G,r7� .s ✓ .r #19-'1"-1 1 ..i 7L, - 1 77 f ? ,' -:/'157 ,Od9—�rIS'" Signature: '-"' Date: �!/�-7/7 Print Name: 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 LSE ONLY Route to Sys Admin: Date t(� /q By '77 Route to Records: Date y'j By /WO Refund Processed: Date(, /7 A By .01 Invoice Processed: Date By Permit Canceled: Date (f/7 f,ig By rh•• '. cel Tag Added: Date By I:\Building\Forms\RegPermitAction_1 0518.ddoc ` / Ir)ItOIiI( IIll11\I1 1G'Iwctrirel J'c milt 1t !»lien t 7""C 'l/E I Received 1çd11_,0j1 • i •INr I) 97227 2 4 201J Pi kw ReYkd Permlt a; 503,7112ao APR Moil: riganiilulkitnshm+ilagilJttnl•nritOV •�'j(,A• 1 ,1ll.wny, f+rr 16 SKrouetk. 1 i 1 ,1`I' Ittr(lrcihttt line: 503,639.4175 Internet:Or. 4.• tm.c, Method aappteae.tat laf.rmati.a ""!"` rim or WO $ ' �' V PLAN RRVIiW CrAdJition/altcratlnnhq►laconcnl Meow cheek all Mat apply(submit lien ofplant wmeme checked). New eutnsWetion O Retake a feeder 400 amps a mot Ono kliat ores three storks. OIhlf: et Ow available fault current O Medan end boom& (" nrtno}ifitxt whtweed.I0,000 amps N 130 volts a O Matins!ruddier J CATEGORY OF COMS1RUCtION buildingken so ground,or exceeds 14.000 OCmnmenial.useaurkaUwn1 ❑I•and 1•hmily dwelling 0 ComincrctnVindusMal 0 Accessory amps fo►an Alter Ie+nrwlo.a. WOOD. 0 ML�ttx bUildtx ❑Other. O Fit pump. O Innannina of I so KVA re 111u1ti•fatnl) D iKMy seem. leasersapnatey/sewed JOB SITE R INFORMATION AM) LOCATION p Addition of new motor bad of system. Job alto address: t,op V0\� -I AL Syr I001tr or mom. O'A',-r,'1.r,'I-r, JAb N: p six or more residential units. occupancy. ❑Heaklrurs Aciiitka. O Recreational vehicle parks CI Hazardous dew locations. O fi .td7,IP:T; l ZZ3 0 Supply wiles+)for more era Suitefild(L/I M. O U n. 6'c win rw>atitki Project name: Q h O Service or Wet 600 arms or wort FEE SCHEDULEf;1+Oss street/directions roJob alter •t 1 eq. I rats I Taal ) • New residential single-or multi-family dwelling snit l Lot N: Includes attached garage. _ 4 Subdivision: 1,000 sq.IL or btt 168.34 Tax map/parcel N: Ea.add'i 300 sq.fl or portion 33.92 i t rOESCRilTION'Orr WORK . -, ' • Limited ener8Y,residential 73.00 2 � ( q�j with above sq.A.) pC l. , &CQ Qxt IONS-41 L<<1i fic, Limited energy,muki-family 75.00 2 TTT residentialabove scL A) 0 See Faze 2 Renewable Enmity YY '�rROrER7V OWNER ,,,"..t,e"'i 'V - Cl'TENANT '••' Services or feeders Iastallatlonoltersdon,and/or reload*o 200 amps or fees 100.70 )�G 2 None t,� bin YI -U 201 amps to 400 mops 13336 2 Adams: viol 0 S iv H 4 f h tA.UP 401 amps to 600 amps 2003 44 2 , City/State ZIP:q 1.1 4J c 0 e,q 1 Z.2.3 601 amps to 1,000 amps 302.06 LJ Over 4000 amps or volts 2 Phony(5ta3)$ S Z SO V Temporary services or feeders lnsbUon ad ,alteration,and/or Email: C. ta1Li a;1.(0(i 1 relocation Owner InataUatbs: it �ftl is being made on propertythat I own which is not 200 amps or leas 39.36 '123.08 2 intended for sale 1ase.rent.or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps Owner signature: Date: 401 amps to 400 amps 128.08 2 Snack circuits—new,alteration,or extension, panel '.0 CONTACT; N A.Fce for branch circuits wall (� f r)tG d r(` above service or fader fee, is' 7.42 11 1.30 2 Business name , �' ,--co atet arch bmmeti circuit B.Foe the branch circuits without Contact name, ,...1A ty service a fonder fee.first 56.18 2 Address: �\3() .e , a (r C..._C. branch circuit y.� Each add'I branch circuit 7.42 2 Ciiy/Sbte21P: diO Q 7 1 Miscellaneous(service or feeder not Included) Phone:(.50) 7 -I - Each manufactured or modular 67.84 2 J g (( dwelling,service and/or feeder Email: cik.�nQ yjC._I4L. , Q imts.Aa onN2 Reconnect only 67.84 2 . . '') . . CONTRACTORS...) i" .. pump or irrigation circle 67.84 _ 2 Business name de_.lif le Signor outline lighting 67.84 2 Signal circuk(s)or limited-energy D See Page 2 (2 Adtfttxr 17.1_ ram, , �q N._ C�— rend,alteration,a extension Each additional inspection over allowable In any of the above aty/StatafZir: c �/ ;:y:,`''nY f 1�� 'Additional inspection(i hr min) 6623/hr Phone: Phone:MI ) 9 Lf 1 Investigation(1 hr min) 90.0W hr ` industrial pleat(1 hr min) 78.i s/hr Email: �;k.h� t'�c_C t" C,�,S41C V �NC�+1k Ct7w� Msparialpons for0hr no feu is 98.18ht t7CB Luc.: »g(,g ) tx Wert Uc•L', 4 Supev.Lie: 5 speeifially listed(u hr min) Sultry.Electrician siputt ra,requited` � � ELECTRICAL.r)CA FBLs Print natnC�` iSubtotal: 2 i 2_ titC�) atC 1 per Q� )(� y O Plan Review Requited(23%ofpamit fee): 7 / State surcharge(12%of permit feet L S• Authorized signatureTO ne per err ra: .?3�] . Print name 711e permit appiu mines 5.a in waft.If aft I.met.tttadsed wltus Ile Osterdays der It bat bee.atxepted as eon pkM. a 41kAlw wu.v+tle_ _ �•.J r Number of inspections allowed per permit tvra�_aa_Iraaa.a a..!uterus att►dutrtl: mvwa