Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City 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): /
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#: Y -1(i ,
Site Address or Parcel#: q.Sa ) -04-e2('I6A� Rd
Project Name: C rj elll D K cV-
Subdivision Name: Lot#:
EXPLANATION: C CM24 C:1 l.tp) :ccl4c. ak. )/1�/G C4i
Signature: (WA 1 Date: q l ,Q
Print Name: 141Vn
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Sys Admin: Date cl'7 k By Route to Records: Date By
Refund Processed: Date • a., By Invoice Processed: Date By
Permit Canceled: Date AD., By Parcel Tag Added: Date By
I:\Building\Forms\RegPemiitAction_120518.doc
9/7/22,9,-28 AM , https://reports2.paygov.us/Account/Receipt.aspx?orderld=9786370
Confirmation Number: 9786370 vo a
Oregon
City of Tigard
PERMIT CENTER
Transaction Details Credit Card Payment Address Information
Order Number 9786370
Refund Reason Customer Name Jennie Lee
Duplicate permit created and paid.
Refunding fees. Email Address admin@modernplumbing.us
First Name Address
Jennie
Last Name Credit Card Number 4XXXXXXXXXXX0645
Lee Credit Card Type
Original Order Expiration Date 1026
9739858
Refunded By Operator Name
ortigardpermit Transaction Time 9/7/2022 12:28:27 PM
Authorization Code
Transaction ID 2066887525
Agency Total -1300.96
Convenience Fee $0.00
Total Amount -1300.96
Charged to Card
comment Duplicate permit created and
paid. Refunding fees.
For questions about this payment,please call (866) 480-8552.
Disputing a charge with your credit card company may result in an additional $40.00 charge.
https://reports2.paygov.us/Account/ReceipLaspx?orderld=9786370 1/1
c
CITY OF TIGARD RECEIPT
1111 I ' 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD VOLD
Qn IProject Name: Crown Oaks Apartments Liy- Cam(Site Address: 9500 SW GREENBURG RD 4
Receipt Number: 442121 - 08/26/2022
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2022-00327 Expansion Tank 230-0000-43101 $100.08
PLM2022-00327 Garbage Disposal 230-0000-43101 $200.16
PLM2022-00327 Sink 230-0000-43101 $400.32
PLM2022-00327 Tub/Shower/Shower Pan 230-0000-43101 $100.08
PLM2022-00327 Water Closet 230-0000-43101 $200.16
PLM2022-00327 Water Heater 230-0000-43101 $300.16
Total: $1,300.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 9739858 PUBLICUSER116 08/26/2022 $1,300.96
Payor:
Total Payments: $1,300.96
Balance Due: $0.00
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