Permit 1,11 .
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s
City of Tigard
TIGARL7 Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Bath Fitter DATE: 11 /23/2010
11747 NE Sumner
Portland, OR 97220 REQUESTED BY:
TRANSACTION INFORMATION:
Receipt #: 179362 Case #: PLM2010 -00293
Date: 9/3/2010 Address /Parcel: 14085 SW Hall Blvd.
Pay Method: CreditCard Project Name: O'Connell
EXPLANATION: Per applicant's request as permit was not needed. Refund 80% of permit fees.
REFUND INFORMATION . '_' €
Fee Description From Receipt Revenue Account No" wit `Refund' 1 '
: Example: Building. Permit Fee, Example ' 23000.00 43104 ' F , . i, ` . :V ount'
Plumbing Permit 2300000 -43101 $58.00
12 °/o State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager M
If under $25,500 Department Manager V
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
: 'TOR TIDEMARICSYSTEM ADMINISTRATION USE QNLY 4-
Case Refund Processed: Date: 7, ,,, /ie> By:
I:ABuilding \Refunds\ RcfundRe x 09/01/2010
11/10/2010 12:34 5035956051 PAGE 01/01
— – CITY OF TIGAR➢ PAGE ` "{/t. aii
11/10/2010 10:53 5035921960 ,q74/4/: ;ft ∎ ?�.ti l
LA
11, Community Development
Request for Permit Actions
i ., l t 1 ,A„ r l a it i � � '
TOE CITY OF TL :"..ARD No\I 1 ® Z010
Building Dior 9i00, Services Coordinator pF TIGA�
13125 SW Hit Blvd., Tigard, OR 97223 CITY ISION
Phone: 503 -711 ,2430 Fait: 503.598.1960 wcSRv_ta ttrd -or. iv BUILDIN t
FROM ❑ Owner PJApp3i ❑ Contractor 0 City Siff
(heck onc)
REFUND OR Name:
INVOICE TO: (riucincas or Tndivid r ]) f r
Mailing Addy Is: _ _ alit " A)
City /State /.7_', i,: e b (A'l-w'Y' a IL, 9 Z O
Phone No,. 9) *5 S (
PLEASE TAKE ACTION PO It TI ITEM(S) CHECKED (
C
VOI
ANCEL P K.vn r APPS CATION -
kt REFUND PERMIT FEE,; (attach xccci 'it:, if available). `
$ INVOICE FOR FEES Di :I'E (attach cave fee schedule and cxplaiia below). / Q
0 REMOVE CONTRACT( ' FROM PERMIT (do not cancel permit).
0 ------
Permit: #: ' i D D c '`i 3
Site Address or Parcel #: , L 0 r JG) 6c-e (5 u
Project None:
Subdivision Name: Los #:
EXPLANATION: r a I� (� (�Q �l9✓ J A.
u ' r r
Suture: A Date: Lc- (i_.4.()
Print Name: k .I.' L j�' —
T. 'ihc Director or i$Iiildirg officio] may aui t v itr the rcflrnd oF:
R) any fee which was crrnnoraual , psdd or ollcaad,
b) nut mere than WA ryr the land uar, apl 'leaden For when an application ir, withdrawn or canccltd hcrorc any rtnAmir effort ban 'been sari ri icd,
c) not metro than 80%n of the land uRe am Ir ith,,t fee for issued permit.
riot men: than 5 ' the lNrilciingpia review fcc when an appileetir,n it canceled hrfbre any plan review efFnrt Iron been eupondcd.
4 not rno,r, than 6O% of he building pet lit I'be For imicd perrnita pnox to aryy Mapccticm xcyuear*.
- Tirhtnda will be returned tp the original tar Kin nce aatm method in which payment war, received_ Please allr 1- 2weelol for, pmrocerging rcfund4.
,- 1 O It (U .1 i1`C 1, 1,1'1:,'('.).T•41,1'
Rtc to 5.9 Aclmin Date 13 Rrc to l ld. A,dmini T)ite /- 9 to H .f..SM
rii,c,fund Proceaged: Date a - te, I3 ,, ,Invoice Proaeaned! Datc B.
Date o � 1 natcel Tel: Aided; B
Roc&••:# - - �, Drotc .. /p Mcthod
i: \J3uifglinR \ Forma \taag3reernfrArricm. T, ewr li7 /26/07
City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
m AyA
IIII
< .4.4 „ '::,;:k
December 8, 2010 4 . � ::
ci
Bath Fitter
11747 NE Sumner
Portland, OR 97220
Attn: Elizabeth Martin
Re: Permit No. PLM2010 -00293
Dear Ms. Martin:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 14085 SW Hall Blvd.
Project Name: O'Connell
• Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $64.96.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Per applicant's request as permit was not required. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
j ��7�
Dianna Howse
Building Division Services Supervisor
Enc.
I: \Building\ Refunds\ Administration \LtrRefund- CancelPemutdoc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 s • www.tigard- or.gov • TTY Relay: 503.684.2772
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Bath Fitter DATE: 11 /23/2010
11747 NE Sumner
Portland, OR 97220 REQUESTED BY:
TRANSACTION INFORMATION:
Receipt #: 179362 Case #: PLM2010 -00293
Date: 9/3/2010 Address /Parcel: 14085 SW Hall Blvd.
Pay Method: CreditCard Project Name: O'Connell
EXPLANATION: Per applicant's request as permit was not needed. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt . Revenue Account No. _ Refund
Example: Building Permit Fee . • - Example: 2300000 - 43104 ' $ Amount
Plumbing Permit 2300000 -43101 $58.00
12% State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager M
If under $25,500 Department Manager V
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION,USE ONNLY
Case Refund Processed: Date: I /A /7 / /e) � B y : *
•
I: \Ruildin \Refunds \RefundRc l ucst.dnc x 09/01/2010
q
CITY OF TIGARD RECEIPT
711 2 . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
R c �61hl
Receipt Number: 180623 - 12/07/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010-00293
$ -64.96
Total: $44.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT I
Credit Card 004427 DHOWSE 12/07/2010 $ -64.96
Payor. Bath Fitter
Total Payments: $ -64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
U1
IIIII C . _ 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
D/ / E /n/4 L.—
Receipt Number: 179362 - 09/03/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00293 Tub /Shower /Shower Pan 2300000 -43101 $12.51
PLM2010 -00293 12% State Surcharge - Plumbing 1003100 -24001 $8.70
PLM2010 -00293 Minimum Fee Adjustment - Plumbing 2300000 -43101 $59.99
Total: $81.20
1
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 004427 DADAMSKI 09/03/2010 $81.20
•
Payor: Bath Fitter
Total Payments: $81.20 •
Balance Due: $0.00
Page 1 of 1
. '11/10/2010 12:34 5035956051 PAGE 01/01
_
CITY OF TIGARD PAGE 81/111
11 / 10/ 2810 10:53 5035981968 /11//1/ : ri; zle k
!Ai --' Community Development
Request for Permit Action
r It. : n i S { . E l
TO: CITY OF TI A RD 1\10V 1 2010
Building Div siott S ervices Coordinator
13125 SW Hall Blvd., Tigard, OR 97223 c OF TIGARD
®N
Phone: 503.711.2430 Fax: 503.598.1960 www.6gatd -or,ge v waDING DI VISI
FROM: ❑ Owner 74, Applicant ❑ Conttaactor ❑ City Staff
(check one)
•
REFUND OR Name: -k-tP-f.
• INVOICE TO; (R>�eE Of ]ndi &MA
Mailing Addy. Ps: - I l '- 141 / V
cit /z p: e b �. aL 7 r-D
Phone No,: )V 5 C' S (1-1'
PLEASE TA= ACTION PO Et THE ITEMS) CHEMED ED (
. CANCEL PERMIT APP1 [CATION.
REFUND PERMIT FEE (attach receipt, if available).
INVOICE FOR FEES D1 JE (attach case fee schedule and explain below).
❑ REMOVE CONTRACT( 'R PROM PERMIT (do not cancel permit).
Pew #: ZD D - p t 93
Site Address or Parcel #: 1(1 C 5( (Sill
Project Name: _ _ .
Subdivision Name: ' _ " Lot #:
EXPLANATION: (A N u L L l____TlffYI : , , u, ( 1
1.R y� -
Sip-mac _ /l_ Date B— 0 —a)
Print Name: ? . L eirk /
1. The 17it>:ttpt or Witting Officio' may nosh* to the tensed oft
a) any fee which veoe ermnoopdy paid ea allotted.
b) not mere than 8Q'fm attic lurid um qpi lotion fee when an appliadoon is withdrawn or canceled bei'ore any onion effort here been cxpae+dcd.
a) not mato than SU% of the land use apt Won fec for issued permits
d) not more than WA of the build - mph- rnicw fee when an applinvine is canceled belt= :nay phm review effort hoe been cepareded.
c) notnrerhx Om BO% nf the buildingper dt fbe rot isenutt1 Damdta prior to Any Inspection straw
2. Ream* *rill be mental to the odpjnal Payc in the saint method in which mean was tcedvcd. Platt Id1mr 1 -2 aeeclta for plot:ming refunds
t m C71:1 ICI: !.ISI OiJJ,1
Rte to S • - Adrift: Date MEM Rte to B :.: Mmits • • to ,02 4!l
Refund Processed: Date Ai /Q E Invoke Processed! Date B •
I= ENEW111 Permit Catteded: Date r ,QI Panel T : Added: Date UM=
Drag Method t- Amount , 1
lAs tri7dinitFetma \Req ?ehmltAetion. 17/26/117