HomeMy WebLinkAboutELC2022-00407 (3) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENR \/ n
111
Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ww-w.tigardror
f r
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) Hillsboro Electric LLC
Mailing Address: 8285 Evergreen Pkwy#110
City/State/Zip: Hillsboro, OR, 97124
Phone No.: 503-439-9666
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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#: ELC2022-00407
Site Address or Parcel #: 16200 SW Pacific Hwy Ste 0
Project Name: T-Moble Tigard
Subdivision Name: N/A Lot#:
EXPLANATION: The site address is completely wrong.
Signature: /<2 ,,rL L�C./L�2.060A. Date: 6/30/2022
Print Name: Kristin Lichtenfels
Refund Policy
I. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date By
Refund Processed: Date 3\22-12.3 By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc
114 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: Hillsboro Electric LLC DATE: 2/22/2023
8285 Evergreen Pkwy#110
Hillsboro,OR 97124 REQUESTED BY: Holly Van De Wege
TRANSACTION INFORMATION:
Receipt#: 441056 Case#: ELC2022-00407
Date: 06/21/2022 Address/Parcel: 16200 SW PACIFIC HWY
Pay Method: Credit Card Project Name:T-Mobile Tigard
EXPLANATION: Refund requested by customer due to wrong address. 80%refund
REFUND INFORMATION.
Fee Description From Receipt Revenue Account.No.` Refund
Example: Building Permit Fee Example: 2300000-43104 .,3 $Amount
Branch Circuits wo/Purchase Service or 220-0000-43103 $145.86
Feeder
12%State Surcharge-Electrical 100-0000-24001 $17.50
TOTAL REFUND: $163.36
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff /fc / 1/j4'i./VP/]'fled
If under$12,500 Division Manager O"
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: By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010