Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
_. • "
•
: 1 Request Permit Action R ECEIVED
- r lc; A R I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tig4i &o202012
TO: CITY OF TIGARD BUI LDINGDIr itij
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 (j n
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov \ I `1' J
FROM: 1 Owner ❑ Applicant ❑ Contractor ❑ City Staff /.Z /, y
(c heck one)
REFUND OR Name:
INVOICE TO: (Business or Individual) (... 8 r L (4. A/4 Li_ 6—
• M ai ling Address: am - -6' ".�3 f 4�36 6 -1 ",..I( S+
City/State /Zip: t 4, Et- °"'..4-9' / /
Phone No.: C4 3) 3 g7- 75-7 7 d f eg
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
iga CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: " i t,_ i t,_ 5r 2. o i 2 00 q( Q 6.11 12-aq. v q
Site Address or Parcel #: /..). 7fi8' f -,* •_ et.,,__ L..-.
Project Name:
Subdivision Name: / 4f 1 . vt, de.. , f. 4..-15 Lot #: if
EXPLANATION: 2 .,.., --4:c - 3 ,•t,c,., /l-... 47,. ce,+., 1 ° ' 4--
aEL Hrada -ooaAo
Signature: C/ . e_____ Date: 9/.2 •/�
Print Name: i ,,! 7o .,,..- _ f
Refund Policy
S03 – 7 53 81 C) f � 3// z 9 Ce 'A d-T� 9-r y 7o '9
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1. The Director or Building Official may authorize the refund of: / !r" � A,
a) any fee which was erroneously paid or collected. � �Sfi46�7 /T/ -ter-- ?a /O /_
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. gps ( 20/2 , ._
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. Ooo6 ? .
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 a Qn' : Rte to Bid: Admin: Date "AUBE B 4e,
Refund Processed: Date Aff,111.1 B OrrAZ Invoice Processed: Date ,j7._ irAll B _•,_C o,, ,
Permit Canceled: Date i 2 2 /- -By 4 t ' Parcel Tag Added: Date By
Receipt # Date Method Amount $
1:\ Building \ Forms \RegPemvtAction.doc Rev 05/25/2012
o CITY OF TIGARD
111111 •
Building Division
TIGARD 13125 SW Hall Blvd.,Tigard, OR 97223 503.718.2439
INVOICE
TO: Stone Bridge Homes NW LLC Customer ID: 173318
4230 Galewood St., Ste. 100 Invoice No.: INV2012 -00008
Lake Oswego, OR 97035 Invoice Date: 08/22/2012
Date Due: Upon Receipt
Case No. . . Site Address . Subdivision - Lot # or Project Name Amount Due '
MST2012 -00081 12758 SW Willow Point Ln. Arlington Heights No. 3, Lot 115 $1,181.50
Invoice Total: $1,181.50
® Please see attached fee schedule for description of fees due.
(Detach and return this portion with payment.)
Case No.: MST2012 -00081 Customer ID: 173318
Site Address: 12758 SW Willow Point Ln. Invoice No.: INV2012 -00008
Project: Arlington Heights No. 3, Lot 115 Invoice Date: 08/22/2012
Date Due: Upont Receipt
Invoice Total: $1,181.50
Amount Paid: $
Office Note: Forward copy of receipt to Dianna Howse when paid. .
Please mail payment to:
City of Tigard, Building Division
Attn: Dianna Howse
13125 SW Hall Blvd.
Tigard, OR 97223
I: \Building \Accounting \Invoice.doc 01/14/2011
CITY OF TIGARD FEE AND PAYMENT HISTORY
I n _ 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIIGARD
MST2012 -00081 - 12758 SW WILLOW POINT LN, TIGARD, OR 97224
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt # Due
Plan Review 230 -0000 -43106 $751.34 $751.34 $750.00 4/18/12 Credit Card 186367 $1.34
Plan Review 230 -0000 -43106 $930.16 $930.16 $930.16
DC Provision Review, SF - Ping 100 -0000 -43112 $65.00 $65.00 $65.00
DC Provision Review, SF - LRP 100 -0000 -43117 $10.00 $10.00 $10.00
Info Process /Archiving - Lg $2.00 (over 230 -0000 -43135 $40.00 $40.00 $40.00
11x17)
Info Process /Archiving - Sm $0.50 (up to 230 -0000 -43135 $45.00 $45.00 $45.00
11x17)
Additional Plan Review 230 -0000 -43106 $90.00 $90.00 $90.00
Totals for Fees • $1,931.50 $1,931.50 $750.00 $1,181.50
Receipt # Payment Method Check # Pavor: Receipt Date Receipt Amount
186367 Credit Card Andrew Thomas - Stone 04/18/2012 $750.00
Bridge Homes NW LLC
Total Payments: $750.00
Balance Due: $1,181.50