Permit CITY OF TIGARD PLUMBING PERMIT
COMMUNITY DEVELOPMENT Permit #: PLM2011 -00190
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 06/14/2011
Parcel: 2S104BB04100
Jurisdiction: Tigard
Site address: 14048 SW LIDEN DR
Project: MOSS Subdivision: CASTLE HILL Lot: 26
Project Description: Sump pump and 115 ft. of footing drain. 6/28/2011: Reprint permit for revised scope of work to include only the
footing drain (contractor not licensed to perform work on sump pumpj. DLH
Contractor: INTERSTATE PEST CONTROL INC Owner: MOSS, WILLIAM
PO BOX 248 14048 SW LIDEN DR
KELSO, WA 98626 TIGARD, OR 97223
•
PHONE: 360- 636 -0560 PHONE.
FAX: 360- 636 -4510
•
FEES
Quantity Description Date Amount
115 If Footing Drain 06/14/2011 $87.55
Specifics: 1 12% State Surcharge - 06/14/2011 $10.51
Plumbing
Type of Use: SF 5 Plumbing Permit 06/14/2011 $5.00
Class of Work: ALT 1 12% State Surcharge - 06/14/2011 $0.60
Plumbing
Type of Const:
Occupancy Grp:
Stories:
•
Total $103.66
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: � l� / p G � n ,�� 0 _ /
Call 503.639.4175 by 7:00 a.m. for the next available inspection date. c /V
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.
Jun 14 2011 9:36PM HP Fax page 3
Plumbi /1 Permit Analicati
Buildin Fixtures C.EIVED
FOR OFFICE USE O[LV
City of Tigard IUN 14 2011 Received
13125 SW Hall Blvd., Tigard, OR 972 Date/By. s �� Permit No.: I/ Ro
• iii Plan Review ���
Phone: 503.7182439 Fax: 503.59 OF T IGA RD Date/By: Other Permit Nc.:
Inspection Line: 503 639 4175
7 i GARD Internet wcvw ttgard or gov G DIVI Notified/Method:
; � 5 TIDING as See Page 2 for
1t r i yiP A,li , 3 " 4? zilf4¢lg p p esi KX: "z�1 y ;, i , s, , n pr3a pPs=r5 M� Supplemental Information
33',,Sp-, R1 t ill .�',.. <, , v 8' 41% .. x a •k ..v x „ u. ' . e ss''Ol i Jo - ? e 5 - .s' °a as
Y 1. .,41rd,,.:8•ta,iii3w u >"� .. a `ti,- 8>• y -' e . � �..: .: ,1k 9 w .. 4`P f.. sa.. �' i �u�, ;ii ir h , °..: D V i 61 k1 ,1�Y.'k W:d' t all r ..1, y
5Gj�a�sa.. 15 � "�a�;«ln .r � � fa 1 a �i s �k p S a.�y� r f � � p .n x .>g I��klf���it u�,�J pl a� F
.ara..3.Wr.Fi. su.. 2. ' t.�u.tmo-a °,"tffi t8.:.x ua�.ak1 1„w:".es'.''," wa i, �..,l+a ,i4`L�r "��.:Etx£v ^3'fd4df s
❑ New construction ❑ Demolition For special information use checklist,
❑ Addttlauonheplacement ® Other: Description Qty. Ea. Total
on/alter
rPrli,m , ti a .,. 1 ati v° it teases R y x g, r New 1- 2- family dwellings (includes 100 ft. for each utility connection)
I K h L� d �t ;a4 ' �n i s C , `:1 r` t' k _ � § �.Wrc��'� � `sx `",. r � C'
a.::�� 4r+ til,h,,.Ql.hw..u�z.•E� .�i��mr.� �& 5FR(1)bath ' 312.70
® 1 and 2 family dwelling ❑ CorrtmerciaVindustrial SFR (2) bath 437.78
❑ Accessory building ❑ Multi- family SFR (3) bath 500.32
❑Master builder Each additional bath/kitchen 25.02
El Other:
" ¢{� r tf u rtr c rr w' Fire sprinkler ( s . R.
cl ubs,$�iPJ ti ^ im,yz �1 $ "�."20'P « t t -lilrt• N;7 d `a �FP"''itgn� :s# x °ini ik l Q ) Page 2
& .f ; �YS,rs aiif iiX�ll ;14"w: Ili '3S, ,., fi:'po`. ::;* *:''. kc- r5 #sw..k.S: �l. #...: Ar,:r §fl a Site utilities:
Job site address: 14048 SWLiden Dr ` Catch basin or area drain 18.76
City /State/ZIP: Tigard Or. 97233 -2634 Drywell, leach line, or trench drain 18.76
Suite/bldg./apt. no.: [Project name: Moss Footing drain (no. linear ft.: 115) Page 2 r Q 7, S.S
Manufactured home utilities 50.03
Cross street/directions to job site: Manholes
18.76
Rain drain connector 18.76
Sanitary sewer (no. linear ft.: ) _ Page 2
Storm sewer (no. linear ft.: ) Page 2
Subdivision: Water service (no. linear ft.: _) Page 2
Lot no.: _ Fixture or item:
gg����Tax map/parcel no '�s , Backflow preventer 31.27
ilillI i li #"jp; .0,:" i ifP a'§ LUy4i l '� yP i 15 '
3 n .''j 3- l i:u 3 e : z 311 +" .S • . "r�.R q '.'.k�.;;:. Backwater valve
;:ii i.i z ltaiiiW" t llsi , z..:, :t a.. .; ^tr '�.,r � gaa,a :,lea:, u;', :4 u nRs�,�x me? r �`° ", anti' Y e`i �xw .', -t'; 12.51
Install footing drain and stamp pump to pump water to low point drain Clothes washer d��f 25 02
Dishwasher ` /i61 i" 25.02
Drinking fountain 1 �9} n 25.02
' ` { t � k�li"iGa.i tail 't;` .ln xf ra:x ( y r y Ejectors/sump i 1 P io 1 25.02 ''
.L�Ilt2C7�.g1 "tf h v:�':a� kyi. a.,,;� �x i� 3k� .lily f #k � i ,`.`1.n ' _"", ax 4'& 7 isv.''. " P '`# P ea E lion tunic ��(}'(.S ) •«
s ,,,.... ..?... ,., s, ikRig5.a.�.. x �. =ht i21. . x ,mac: 1. `rY�sdd. sepal Gs. n -41 E ' r , 12.
Name William Moss Fixture/sewer cap 25.02
Address: 14048 SW Leden Dr Floor drain floor sink/hub 25.02
City /5tate/ZIP: Tigard, Or. 97223 - 2634 Oar a disposal 25 02
Hose bib 25.02
Phone: (503)590-7978 Fax ( ) Ice maker -
e l , {s9 § , a P tra 12.51
IId IIi . N:jlir a �` l e 1 ` ;h i F x lk l g T ,, y tA 4� r � , k i i'.` +
f 4S,s" l I n te rcepto r grease trap
25.02 i
a..,a,• ,fA.., i"�IZdsa..,a ,;.uxax uw,oa';4 _a�::a &��..x$8.....�§$ .f.:ao:.f°..� i`.•.`- 3.1.r.�.a3"v�. a'.EwEB$ i x ti
Business name. Interstate Pest Control Medical gas (value: $ ) page 2
Contact name: Brad Thorstenson Primer 12.51
Address: P.O, Box 248 Roof drain (commercial) 12.51
5ink/basin/lavatory 25.02
City / State/ZIP: Kelso, WA. 98626 Solar units (potable water) 62.54
Phone; (360) 636 -0560 I Fax: : (360) 636 -4510 Tub /shower /shower pan 1Z51
E -mail: brad@interstatepest.com Urinal 25.02
r � I dIS,h r � y � `x ui # el" !�� a a fi,. 3 & Se: P :r sg m s
it ., ,ii'I' alii ,aa i , i1�r . 1, bile l t ,k t, F ;`' " s 1 e* V J + 44 " 'le i s a1 i'sai Water closet 25.02
at 3, , a i•. ury uw s e�ur.a...l�i t ,t.�9i , ,A k ie.' ., a Water heater -
Business name: Interstate Pest Control 37.52
Water piping/DWV 56.29
Address: P.O. Box 248
Other 25.02 pl. sS
City/State/ZIP: Kelso, WA. 98626 Subtotal
Phone: (360) 636 - 0560 Fax: (360) 636 -4510 Minimum permit fee: $72.50
CCB Lic.: 127319 I i , 0. A Plumbing Lie. no.: Plan review (25% of permit fee) A $ f
Authorized signature. .f l� ` \ i J State surcharge (12% of permit fee) .13.E
TOTAL PERMIT FEE 126.08
Print name: Brad Thorstenson ! Date: 6 /14/2011 This permit application expires if a permit is not obtained within 180 daysg 0
after it has been accepted as complete. 77
"Fee methodology set by Tri- County Building Industry Service Board, �1
1 : 1 BuildinglPermits \PI.MU- PermiiApp.doc 10/01/09 ) e /_T_ _moo 25 r 0 e ee Z = , 0.2.
44 0�616T(10lOUCOhUVJEB �C- t-+r"K A a_
T -7 f . aa. Vo2-
Jun 14 2011 9:36PM HP Fax page 4
Plumbing Permit Application - City of Tigard
Page 2 - Supplemental Information
Fee Schedule: l Fire ti
Residential � � ,,yy 7T Su 1 4 ression S stems: �bE d , ., i4 :- , h ! F Y § . : : _ r d , q h . . : ' ° i�. :S% F''` r g':,: 1..'x1 . a t �r 4' ' 0; �1: ' + : :: .:? ' . , " ^f r.:. =s. .37...'- 1m7,:s ,: i «
h,.¢,e ?si„;,.....w,1,s r,a$sr, .:;:,1;; .::,i, ..u3� "d,+..�;,..,`"eaat «.a + �_t +F,e": ... ,, f i' " v lc.,;, „ : w . w ;a + ; ;"d * . h , " �d$ its r ::.': �{lftl' -ax1 f(I t : �t l°tl.i� :II %
Footing drain -1' 100' 1 50.03 100 0 to 2 000 � �� »��:i.. sp y.. « r t'.r ' : �` �`e "h ::Hkins
$121.90
Footing drain - each additional 100' 1 37.52 30 2 001 to 3,600 $169.69
Sewer - 1st 100' 62.54
7 3 601 a $233.20 4 201 and d : ater $327.5
Sewer - each additional 100' 37.52
Water Service - 1st 100' 62.54 _
Water Service •each additional 100' Medical Gas S stems:
37,52 ,- t u f :, q tic Bz� n ! r , 6 �s v t�°4y� lea xeE3gM,?
� �. rtf i id r a a I $
Drain 1st 100 62.54
.?0.. < , , s r i .3 , ,ll$s.,«Gl,.,a.t,.: l as >, 1 .,w ,zla MIllt Ixl i,ltlllutrt,�i) to
Storm &Rant Dra
Storm &Ram Drain each additional 100' $1 D0 to $5,000.00 Minimum fee $72.50
_ 37 52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for
{f .;,1 11 { Nli 0. . , 4 rt} :a. G ba A« i ;). ;; "`i* d J.. Fr apl a # ,un,, A
' tiro u a Y i F 1 . - w t ,s s a , each additional $100.00 or fraction thereof to
_a., „ ...., 1, , �s:<u r �:a a,3ki StSiI x.t s dx ell and including $10,000.00.
Inspection of existing plumbing or for ■ ■ $10,001.00 to $25,000.00 $143.50 for the first $10,000.00 and $1.54 for
which no fee is specifically indicated 90.00Ihr each additional $100.00 or fraction thereof to
minimum char:e -1/2 hour and including $25,000.00.
Inspections outside of normal business - 90.00/M $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for
hours minimum char e - 2 hours each additional $100.00 or fraction thereot to
Reinspection Fees _ 90.O0/hr and including $50,000.00.
Additional plan review for revisions - 90.00/hr - $50,001.00 and up $742.00 for the. first $50,000.00 and $1.20 for
minimum ch ,e -1 /2 hour each additional $100.00 or fraction thereof.
Subtotal: ___
Commercial Fixture Work:
Are you capping, adding or replacing fixtures? If "yes ",
please indicate work performed by fixture. Failure to
accurate) report fixtures could result in increased sewer fees * .
a §�',l {t�l��t {��IE {Iff'�� y, fp,Y"°':tf)�ilt�xt { tz ,�.:� � �� �� sa,ar�zirYs� w x'7�•9:J'k,: � r'� �w �yh e.«
,lt I '` RK l 111, t c4i . A . ry.� niali . if . i p.1 y t 7. N :- ; gi a 7 J :, 4 a Jr. i, '``c ., e f-ai, 4v ,t..
:. � , �i� �Y � � ,: a �x �s:« � `y `� m � h t &a p �F?ltc �� 9d�mety;«�,�oW fit � 3 �i� ,
,Q2. , a t. ; „I . '�< 5 : c a 3 , Ut. , a tttt ;F P 145 t u7r r. tea:w ..: ,. .. .., 3 ( ...:,..:.:1 t 1 . 3 3� B lrl a t . .r a t
.' f . <_ ., f w i n ,�a. 1 B Uri « 1 � Illiltflri'
li y l l �x li ce t m� 1 i i a z Si 1 fi t . i t l f ,P ; "n "a p . 9 ] + 6'
i s t
t.a;, a t �,,,,„, ,- , -1,�: ��l�a, r , ,�,p 1 t , ,�,�. � � ���;��� ��� � , t � Plan review is require for any of the following.
Baptistry/Font check all that apply.
-
❑ Any new commercial building with water service 2" and
Bath -Tub/Shower -
- Jacuzzi/Whirlpool - greater, except systems designed and stamped by licensed
Car Wash -Each Stall engineer
-Drive Thru 0 New exterior plumbing site utilities for any complex structure
_Cuspidorl�vater Aspirator as defined in OA1t918- 780 -0040.
Dishwasher -Commercial ❑ Medical gas and vacuum systems for health care facilities.
- Domestic ❑ Any multipurpose fire sprinkler system.
Drinking Fountain ❑ Any complex structure as defined in OAR9 ] 8- 780 -0040.
Eye Wash
Floor Drain/sink 2° Submit 2 sets of plans with any of the above.
- 4 „'w +, , " Ya ""^��••".a n,�i Et + gyp rti sx, i i ff� i��d m"lh "a
�yN il�ti� « f «
Car Wash Drain re. kA+..k` i:,t�i..c....:,'�s4, .a„xo,I µ &:t s�F >o « «, Pfwnxs4�!::£'LIII6i5:I, 1
P�
Garbage Domestic-non-food - ❑ Isometric or riser diagram is required for new buildings
Disposal - Domestic -food related that meet the •ualifications above.
- Commercial -food related
- Industrial -food related
Ice Mach./Refrig. Drains
Oil Separator (Gas Station) Comments regarding fixture work:
Rec. Vehicle Dump Station
Shower -Gang
-Stall _
Sink/Lav - Non -food related
- Bradley -
- Commercial -food related - -
-
- Service
-
Swimming Pool Filter
Washer - Clothes ' *Note: If the fixture work under this permit results in an
_ Water Extractor - increase of sewer EDUs, a sewer permit will be issued and
Water Closet - Toilet fees assessed for the sewer increase must be paid before the
Urinal
plumbing permit can be issued.
Other Fixtures:
http : / /www.tigard- or.gov /eity_hal Udepartment skdJdocs/PLMF- PermitApp2d oc
Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: n Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ' / I .2N • I 3 , _ l e C iirei
r
Mailing Address: P J. & » ,9
City /State /Zip: 1(d c-t)f 9r6,60
Phone No.: 4 U 636 -056d ej°
PLE -, AKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
Mr _ ____ ERMIT APPLICATION.
t REFUND . RMIT FEES (attach receipt, if available). rktil
. • O E FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). f\Jrd
Permit #: , )0 / / -od
Site Address or Parcel #: / gtfif. L_, .-ie ►l
Project Name: OSS
Subdivision Name: Lot #:
EXPLANATION: C.ONJ-I- C'k)r Nat I , Cfii1 Se-d `o f'r -eM LJv ,r l.�.
Cam -C-ee-S s uL1- c-fv "f t\e_ r
e � i-e rat c p +V C frcf C C. Lie — ,tc.) resS0/13e_. ,
!
Signature: 4
�/ _ : _ Pate: `c/ 771/
Print Name: Q 2vvae ,, wo rt -
RefundRefund Policy wort-
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date G I7 n By ; Rte to Bld: Admin: Date , B 1%t
Refund Processed: Date
0/24- // By Invoice Processed: Date By
Permit Canceled: Date /4/ /f L By Parcel Tag Added: Date By
Receipt # /( Z t 5 Date �/ f /// Method C e Amount $ /2 60 . C p
I: \Building \Forms \RegPermitAction.d c Rev 07/26/07
ill s: t
y
1
City of Tigard
June 28, 2011
Interstate Pest Control
Attn: Brad Thorstenson
PO Box 248
Kelso, WA 98626
Re: Permit No. PLM201 1 -001 90
Dear Mr. Thorstenson:
The City of Tigard has processed a refund for fees on the above referenced permit(s) for the
following:
Site Address: 14048 SW Liden Dr.
Project Name: Moss
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $22.42.
❑ Trust account "deposit" receipt in the amount of $ .
Notes: Refund 80% of permit fee for sump pump only as contractor does not have
plumbing license required to perform this work. See attached revised plumbing permit and
original credit card receipt. .
If you have any questions please contact me at 503.718.2430.
Sincerely, .
/C-6 /074-77-C___.
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Buildin irH lefi]evEkfmdfigd rdPOttgon 97223 • .503.639.4171
TTY Relay: 503.684.2772 ® www.tigard- or.gov
CITY OF TIGARD
I II n RECEIPT
2 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 182865 - 06/14/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2011 -00190 Footing Drain
2300000-43101 $87.55
PLM2011 -00190 12% State Surcharge - Plumbing 1003100 -24001 $10.51
PLM2011 -00190 Plumbing Permit 2300000 - 43101 $5.00
PLM2011 -00190 12% State Surcharge - Plumbing 1003100 - 24001 $0.60
Total: $103.66
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 02593C BTAGGART 06/14/2011 $126.08
Payor: Bradley Thorstenson / Interstate Pest Control
Total Payments: $126.08
Balance Due: $0.00
/q777 CT r
Accela
System Administration
Finance De artment Re uest .
Date: _k_i_ogfia—_ .
To: • Liz Lutz
Kathy Gende
From: Dianna Howse/
F2 P6_S
Re: Receipt #: /Fa
Please process this request as follows:
Journal Entry (route copy of JE to
Dianna Howse).
Reversal (fees have been reversed on
Revenue Account Report).
•
Credit Card Return,(fees have been
reversed on Revenue Account Report).
Other /Ex lanation
Thank you! 1/1V--.
I: \ B \FormAllteSlip Fi nanceRe q .doc
Page 1 of 1
,' CITY OF TIGARD RECEIPT
a 13125 SW HaII Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 183049 - 06/28/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2011 -00190 fi-4/i6 r -/ ,..700000 -- 9:3 /0/ 07 e aZ,
�, S a / : SC[/LC'�9iZCzS
/j/c1 / $ - 22.42
�
fcc 3ico - �ycoi
Total: $ -22.42
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 02593C DHOWSE 06/28/2011 $ -22.42
Payor: Bradley Thorstenson- Interstate Pest Cont
Total Payments: $ - 22.42
Balance Due: $22.42
•
Page 1 of 1
•
1 111 CITY OF TIGARD RECEIPT
a : 1312 SW Hall Blvd., Tigard OR 97223
503.639.4171
T1 \ I)
6 / / • , ' i 4 Cr.
Receipt Number: 182865 - 06/14/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2011 -00190 Footing Drain 2300000 -43101 $87.55
PLM2011 -00190 Ejectors /Sump 2300000 -43101 $25.02
PLM2011 -00190 12% State Surcharge - Plumbing 1003100 -24001 $13.51
Total: $126.08
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 02593C BTAGGART 06/14/2011 $126.08
Payor: Bradley Thorstenson / Interstate Pest Control
Total Payments: $126.08
Balance Due: $0.00
•
•
•
•
Page 1 of 1
City of Tigard
T I GA RD 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: Interstate Pest Control DATE: 6/28/2011
Bradley Thorstenson
PO Box 248 REQUESTED BY: Dianna Howse
Kelso, WA 98626 Branden Taggart
TRANSACTION INFORMATION:
Receipt #: 182865 Case #: PLM2011 -00190
Date: 06/14/2011 Address /Parcel: 14048 S\V Liden Dr.
Pay Method: CreditCard Project Name: Moss
EXPLANATION: Contractor does not have a plumbing license required to perform work. Refund 80% of
fees collected to install sump pump only.
REFUND INFORMATION: •
,Fee Description From Receipt Revenue Account No:'. 'Refund • •
Example: Building Permit Fee Example: 2300000 - 43104. $ Amount
Plumbing permit fee 2300000 -43101 $20.02
12% State Surcharge 1003100 -24001 2.40
TOTAL REFUND: $22.42
APPROVALS:
If under $5,000 Professional Staff -
If under $12,500 Division Manager I !♦ �." ) G / i'jj1
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
• FOR TIDEMARK SYSTEM ADMINISTRATION USE ON
Case Refund Processed: I Date: I (,o 2e//� I B I .�, 1''
c
I:\ Building \Refunds\ Refundltcqucst.dtx x 09/01 /2010