Correspondence F 2. R
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City of Tigard
October 20, 2011
Martha W Worley
9695 SW O'Mara St.
Tigard, OR 97223
Re: Permit No. ELC2011 -00171
Dear Ms. Worley:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9695 SW O'Mara St.
Project Name: Worley
Job No.: N/A
Refund Method: ® Check #204333 m the amount of $63.64.
❑ 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.
❑ Trust account "deposit" receipt in the amount of $ .
Comment(s): Per applicant's request as scope of work changed; replaced only switch
plates; refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
1.\su,id», \Refunds1. 12,45,E Wnia YSLPPI,ig4doarnon 97223 0 503.639.4171
TTY Relay: 503.684.2772 ® www.tigard- or.gov
II
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 1 ennztActzon 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: Martha W Worley DATE: 10/18/2011
9695 SW O'Mara St.
Tigard, OR 97223' REQUESTED BY: Dianna Howse
Applicant
TRANSACTION INFORMATION:
Receipt #- 182026 Case #: ELC2011 -00171
Date 4/5/2011 Address /Parcel 9695 SW O'Mara
Pay Method. Check Project Name: Worley
EXPLANATION: Per applicant as scope of work changed; replaced only switch plates. Refund 80% of
permit fees.
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Electrical Permit Fee 220 - 0000 -43103 $56.82
12% State Surcharge 100- 0000 -24001 6 82
TOTAL REFUND: $63.64
APPROVALS:
If under $5,000 Professional Staff 4 : 1Lf1/p/i
If under $12,500 Division Manager
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
T
"FO.R�TI
-iDEMARK SYSEM'` ADMINI-ST_RATION: =USE'ONLY �A
; °� � : `�, . y ":, `' ,�'a%�, .... ., ,. _. _ � - .� � Y' . ,t ry . may, :F.,>
Case Refund Processed. Date. . ZO, By. t f l __._
I \Build,ng\Refunds \RcfundRcqucu doc N 09/01 /2010
Community Development
T t c n li 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: Owner ❑ Applicant n Contractor ❑ City Staff
(check one)
REFUND OR Name: I �
INVOICE TO: (Business or Individual) �14,,y- "kez,„
Mailing Address: % Su.) v t a/r - S
City/State /Zip: 7 7_2-3
Phone No.: L93 ���f — ��� 5
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
n,NCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: FL o ?e2 // -- p p /7 /
Site Address or Parcel #: m of le /G p v e--
Project Name: ij be
Subdivision Name: R /a Lot #:
EXPLANATION: h7 h e- -re( n n
(mil tt-0 e-- eliGc - - Cr/4/ 7 � �C � e St�v C"_�i �J /4
Signature: 9 , Date: 7/0 c.//1
Print Name: / 4/ai01 • We ✓/e,
Refund Policy /
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 onginal 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 /0 L / B Rte to Bldg Admit,: Date i Zs B :--
Refund Processed: Date (0 "20//, By ',J -, Invoice Processed: Date By
Permit Canceled: Date /, /`j/ By . . Parcel Tag Added: Date By
Receipt # Date / / Method Amount $
I \Building \Forms \ReqPermitAction doe Rev 07/26/07