Permit v
? rte..'_"
City of Tigard
January 18, 2012
Jane T & Roger W McKee
Silverado NW Properties
6000 Suncreek Dr.
Lake Oswego, OR 97035
Re: Permit No. BUP2011 -00209
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 12005 SW 70`'' Ave.
Project Name: Acupuncture Clinic
Job No.: N/A
Refund: ® Check #205193 in the amount of $356.94.
❑ 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.
n Trust account "deposit" receipt in the amount of $
Comments: Refund 100% of school construction excise tax collected in error.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
1: \ spading\Refunasl\31 ASWiHa k; v rAiligacdp cogon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
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: Jane T & Roger W McKee DATE: 1/4/2012
Silverado NW Properties
6000 Suncreek Dr. REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035 DEB
TRANSACTION INFORMATION:
Receipt #: 184538 Case #: BUP2011 -00209
Date: 11/09/2011 Address /Parcel: 12005 SW 70th Ave.
Pay Method: Check Project Name: Acupuncture Clinic
EXPLANATION: Refund 100% of school construction excise tax collected in error.
REFUN FORMATION k _, "_ i , gtf ,. y , , ._ ig - t s , . f
Fee Description From Receipt , Revenue Account No Refund "=
Example Btuldui'Perniii Fee r E'x, ample , 2300000= 43104; $.Amounf
Tig -Tual School CET - Non Residential 230- 0000 - 24102 $356.94
TOTAL REFUND: $356.94
APPROVALS:
If under $5,000 Professional Staff ,
If under $12,500 Division Manager j!
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
Case Refund FOR TIDENIARg SYSTEM ADMINI STRATI ONVSE?ON -1
Processed: I Date: y / //,2___ By: , i/T/
1: \Buih ling \Refunds \RcfundRc x 09/01 /2010
•
CITY OF TIGARD RECEIPT
•
_ 13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
. _ _ TIGARD
Receipt Number: 185200 - 01/18/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
B U P2011 -00209 _ 5 e f i t p 0 L C X 3O -0000 - 2/0 , _ $- 356.94
Total: $- 356.94
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 205193 DHOWSE 01/18/2012 $- 356.94
Payor: JaneThayer McKee
Total Payments: $- 356.94
Balance Due: $356.94
Page 1 of 1
•
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD - -
£/
Receipt Number: 184538 - 11/09/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
B UP2011 -00209 DC Provision Review, COM TI - Ping 100 - 0000 -43112 $256.00
BUP2011 -00209 DC Provision Review, COM TI - LRP 100 - 0000 -43117 $38.00
BUP2011 -00209 Permit Fee - Additions, Alterations, 230 - 0000 -43104 $2,833.39
Demolition
BUP2011 -00209 12% State Surcharge - Building 100 - 0000 -24001 $340.01
BUP2011 -00209 Info Process /Archiving - Lg Sheet (over 230 - 0000 -43135 $46.00
11x17)
BUP2011 -00209 Info Process /Archiving - Sm Sheet (up to 230 - 0000 -43135 $7.00
11x17)
BUP2011 -00209 Metro Const. Excise Tax - Commercial 230 - 0000 -24010 $463.20
Use
"I BUP2011 -00209 Tig -Tual School CET - Non Residential 230 - 0000 -24102 $356.94
Total: $4,340.54
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1003 DADAMSKI 11/09/2011 $4,340.54
Payor: Jane T & Roger W McKee - Silverado NW Properties
Total Payments: $4,340.54
Balance Due: $0.00
Page 1 of 1
I li Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner - n Applicant ❑ Contractor Sr City Staff
(check one)
REFUND OR Name: •
INVOICE TO: (Business or Individual) � Y .00t2 L3. HC Kg_
Mailing Address: 6 000 ..56 /U - ,e_. b A.. q
City /State /Zip: 4.- 054/6 0 /C- / 7d _KS
Phone No.:
X43 — rP7' l °`" 2/ "'
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
H CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt).
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: aGtP // / --
Site Address or Parcel #: /og 0 05 - AA) () 77± 40 -
Project Name: 1)--ett iOo t eL i
Subdivision Name: Lot #:
EXPLANATION: kEt (h e to e 7> /,J &La.
Signature: /, , i , ' 4 Date: /, ///
Print Name: A -/z / lj4C/
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 original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds. .
FOR OFFICE USE ONLY _
Rte to S s Admin: Date �� ®1� �'/j Rte to Bid! Admin: Date / � : `ii/�
Refund Processed: Date / / B 21 Invoice Processed: Date B
Permit Canceled: Date/►// ' By 4 `arcel Tag Added: Date By
Receipt # Date Method c(4__ Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 04/26/2011