Permit •
Pitt
City of Tigard
October 20, 2011
West Hills Development
Attn: Dan Grimberg •
735 SW 158 Ave.
Beaverton, OR 97224
Re: Permit No. PLM2010 -00169
•
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13336 SW Ouzel Ln.
Project Name: Alpine View, Lot 24
Job No.: N/A
Refund Method: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $64.96.
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 building plan was changed for this lot. Refund
80% of deposit, less fees due for development code review.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
L•\ Buildin \Refundsg ,5s &Wn ailfBautlucsaTi d rag°n 97223 ® 503.639.4171
TTY Relay: 503.684.2772 ® www.tigard- or.gov
III c 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: West Hills Development DATE: 10/20/2011
Attn: Dan Grimberg
735 SW 158 Ave. REQUESTED BY: Dianna Howse
Beaverton, OR 97224 Applicant
TRANSACTION INFORMATION:
Receipt #: 178118 Case #: PLM2010 -00169
Date: 5/28/2010 Address /Parcel: 13336 SW Ouzel Ln.
Pay Method: CreditCard Project Name: Alpine View, Lot 24
EXPLANATION: Per applicant's request as building plan was changed for this lot. 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 Fee 230 - 0000 -43101 $58.00
12% State Surcharge 100- 0000 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
If under $5,000 Professional Staff ` If under $12,500 Division Manager -V 4p 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 ONLY .. .
Case Refund Processed: I Date: I /'Q /Z y// I B I d
1:\ Building \ Refunds \RefundRcqucst.doc x 09/01 /2010
•
IIII CITY OF TIGARD RECEIPT
m . . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
A efie /6
Receipt Number: 184293 - 10/20/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00169 S j /9• ei/ s /`nL / ece-ze Ni C'e ,- -s $ -64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 026085 DHOWSE 10/20/2011 $ -64.96
Payor: Dan Grimberg, West Hills Development
•
Total Payments: $ - 64.96
Balance Due: $106.19
Page 1 of 1
CITY OF TIGARD RECEIPT
q
11111 a 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171 I ;) (/
TIGARD
d oe i jit/ /9
• Receipt Number: 178118 - 05/28/2010
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2010 -00169 Backflow Preventer 2300000 -43101 $31.27
PLM2010 -00169 12% State Surcharge - Plumbing 1003100 -24001 $8.70
PLM2010 -00169 Minimum Fee Adjustment - Plumbing 2300000 -43101 $41.23
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 026085 DHOWSE 05/28/2010 $81.20
Payor: Dan Grimberg, West Hills Development
Total Payments: $81.20
Balance Due: $0.00
_cirri r'
n,
�/ 9
Page 1 of 1
•
IN ii,
a Community Development
Request for Permit Action .. /��
CARD ( _
TIGARD
- %l; ;;'1,:D,./ it I
TO: CITY OF TIGARD JUL 61 a
Building Division Services Coordinator 2011
13125 SW Hall Blvd., Tigard, OR 97223 Chr'' -, ,
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov 1�5E1't 'T�Ij,tl p,,i / r
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name: ; _
INVOICE TO: (Business or Individual) ! f /
Mailing Address: 6 ; 3 4 1 fly/ 1 " ' 11/1 i .
City /State /Zip: i// �: � V-i—e F� Cr 6" f /� tt
"r r
PhoneNo.: � l i 0 — 4 0,E `° '. � /
i 1
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ( ? t' . t r � �
�, CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available). I ;,
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain belo . " '. 6 0
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). /4"7/7
Permit #:
X11 7 T 70 Wt0 ?O' I 444
Site Address or Parcel #: /::5-;''';'((' tom''; C I t - /' '1 PL/y' j)0/C,,. /4 7
Project Name: a(G k C (� /11
Subdivision Name: Lot #: /
•
EXPLANATION: .G .,710,A7; ,ii. i' `� t ; -4 - t •
- 15 1
•
Signature: (,,(A;(1{. L � 7 (2 ( Date: j r
Print Name: -- ,:4y, / L..t��, K 9
Refund Policy
1. The Director or Building Official may authorize die 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 $.1 it By Alf % % Rte to Bldg Adtnin: Date /p /u /j B ' .
Refund Processed: Date f e ? i / / j By ' Llvoice Processed: Date B
Permit Canceled: Date j / By�— -. Parcel Tag Added: Date By
• Receipt # Date / Meth od Amount $
I: \ Building \ Forms \RegPermitAction.doc Rev 07/26/07