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Permit . _ ° 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: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) Mailing Address: 12880 SW 121 Ave VOID City /State /Zip: Tigard, OR 97223 /// ,/ f Phone No.: 503- 590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): ® CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and exp below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLM2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121St Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A • EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008- 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ee of $6,534.11. Signature: 1 1 4 J Date: 10/27/08 -Debi Die R. Adamski Print Name: 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date By Rte to Bldg Admin: Date / B Refund Processed: Date / /?/ ,f- By Invoice Processed: Date By Permit Canceled: Date /17 9 r By Parcel Tag Added: Date By Receipt #l1r L,6 9 Date e7 29 /oP Method . � Amount $ I: \ Building \Forms \RegPermitAction.do Re 07/26/07 • 4 ON City of Tigard TIGARD Tidemark Refund Request This form is used for refund requests of land use, engineering and building application fees. Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be attached to this form. Refund requests are due to Tidemark System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark System Administrator for distribution. Please allow 1 -2 weeks for processing. • PAYABLE TO: Sandra Smith DATE: November 3, 2008 12880 SW 121st Ave. Tigard, OR 97223 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2008 -669 Case #: PLM2008 -00078 & SWR2008 -00020 Date: 2/29/08 Address /Parcel: 12880 SW 121st Ave. Pay Method: Check Project Name: Smith EXPLANATION: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount [PLUMB] Permit Fee 245 - 0000 - 431000 $72.50 [TAX] 12% State Surcharge 100 - 0000 - 207020 8.70 [REMDST] Reimbursement District Revenue 500 - 0000 - 479010 6,534.00 [SWUSA] Sewer Connection Fee 500 - 0000 - 207000 2,800.00 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 TOTAL REFUND: $9,450.20 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager If under $22,500 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 /7-3/0" By: I ( I:\ Building \Refunds \RefundRequest.doc 05/23/07 . 1 Y 111 v CITY OF TIGARD SEWER CONNECTION PERMIT ° COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00020 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/29/2008 PARCEL: 2S 103RD - 03300 SITE ADDRESS: 12880 SW 121ST AVE ZONING: R -4.5 SUBDIVISION: LOT: JURISDICTION: TIG PROJECT: SMITH Project Description: Connecting sewer. TENANT NAME: CWS NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: 1.0 TYPE OF USE: SF NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Owner: SANDRA SMITH FEES 12880 SW 121ST Description Date Amount TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 2/29/2008 $2,800.00 [SWINSP] Sewer Inspection Fee 2/29/2008 $35.00 Phone: 503 -590 -3309 Total $2,835.00 Contractor: Contact #: REQUIRED ITEMS AND REPORTS Reg #: This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. i Issued b 411111 ,, Permittee Signature: "i. // Call 503.639.4175 by 7:00 a.m. for an inspection that business day. 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. ..D ........- I 0 El Community Develop 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: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff _ (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) Mailing Address: 12880 SW 121s Ave VOID City/State/Zip: Tigard, OR 97223 / /3 / ' d Phone No.: 503- 590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ® CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and a plain.below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLM2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121'' Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008- 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ee of $6,534.11. \ # Signature: 1 /' 1 ' 4 I j Date: 10/27/08 \ - 1;k45 R. Adamski Print Name: 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. c) 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 By Rte to Bldg Admin: Date /7 .3 /,'- - • FA; ".;,1 B .,.. Refund Processed: Date //17/ / By , ( Invoice Processed: Date By Permit Canceled: Date / / /.i D F By . j • Parcel Tag Added: Date By Receipt #,0,4?—hi, 9 Date J 29/or Method Amount $ I: \ Building \Forms \RcgPemvtAction.do Rei07/26/07 TO: Brian Blalock City of Tigard FROM: Sandra T. Smith 12880 SW 121st Avenue Tigard, OR 97223 (503) 590 -3309 RE: REQUEST FOR PERMIT EXTENSIONS Sewer Connection Permit # SWR2008 - 0020 Plumbing Permit # PLM2008 - 0078 I need an extension on these permits due to my inability to locate a contractor. Contractors that have come on site to provide bids are put off by the "iffy" elevation /slope degree for flow to the sewer connection. f9 Thank you for your consideration � - V C .2_9 01' • Sandra T. Smith August 29, 2008 • CITY OF TIGARD 2/22 9/2008 13125 SW hall Blvd. 1 PM • Tigard, OR 97223 503.639.4171 • • TIGARD Receipt #: 27200800000000000669 Date: 02/29/2008 Line Items: Case No Tran Code Description Revenue Account No Amount Paid PLM2008 -00078 [PLUMB] Permit Fee 245- 0000 - 431000 • 72.50 PLM2008 -00078 [TAX] 12% State Surcharge 100- 0000- 207020 8.70 REMDST Reimbursement District Revenue - 6,534.0000 a: S 1.0000 500- 0000 - 479010 6,534.00 SWR2008 -00020 [SWUSA] Sewer Connection Fee 500 - 0000 - 207000 2,800.00 SWR2008 -00020 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 Line Item Total: $9,450.20 Payments: Method Payer User II) Acct. /Check No. Approval No. How Received Amount Paid Check SANDRA T. SMITH BTT 2459 In Person 9,450.20 Payment Total: $9,450.20 cRcccipi.ryM Page I of PEON E rOpy 8 TO: Brian Blalock �� City of Tigard FROM: Sandra T. Smith 12880 SW 121st Avenue Tigard, OR 97223 (503) 590 -3309 RE: REQUEST FOR PERMIT EXTENSIONS Sewer Connection Permit 4/ SWR2008 - 0020 Plumbing Permit # PLM2008 - 0078 I need an extension on these permits due to my inability to locate a contractor. Contractors that have come on site to provide bids are put off by the "iffy" elevation /slope degree for flow to the sewer connection. r Thank you for your consideration f-� U g, Sandra T. Smith August 29, 2008 • . " t!, CITY • O.F TIGA 10/24/2008 • . : 4 _ 131 -5 SW Hall Blvd. 2:29:44I'M 4 , Tigard. Olt 97223 503.639.4171 '6.1GARD - Receipt #: 27200800000000000669 Date: 02/29/2008 Line Items: Case No Trail Code Description Revenue Account No Amount Paid PLM200S -00078 [I'LUMI3] Permit Fee 245 72.50 PLM200S -0007$ [TAX] I2'1 State Surcharge 100 -0000- 207020 8.70 REM DST Reimbursement District Revenue - 6,534.0000 cis S1.0000 500- 0000 - 479010 6,534.00 SW122008- 00020 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 2 ,800.00 SWR2008 -00020 [SWINSP] Sewer I nspection Fee 245 0000 - 441001 35.00 Line hem Total: $9,450.20 Payments: Method Payer User II) Acct. /Check No. Approval Nu. Flow Received Ailunuil Paid Check SANDRA 1'. SMITH BTT 2459 In Person 9,450.20 • Payment Total: $9,450.20 :r�,riai rp, I'a I .11 I l Bank Reconciliation Checks By Date a a 03/21 /2011- 9:27 AM TIGARD User: kathyge Outstanding Checks Check No Check Date Name Comment Module Clear Date Amount 58273 07/11/2008 Teresa Trexler AP 15.00 58515 07/23/2008 Stephen Allen Barry Jr AP 35.00 58716 08/05/2008 Steven P Naylor AP 25.00 58872 08/07/2008 Jodi Dian Rosenberg AP 75.00 58969 08/21/2008 Kenneth R Erickson AP 75.00 59046 08/26/2008 Russell E Swinhart AP 60.00 59535 09/24/2008 Robert Rohlf AP 5.00 59780 10/07/2008 RAR Communications AP 150.00 59831 10/10/2008 Shubhangi Vivek Sathe AP 15.00 59906 10/20/2008 Scott Timothy Koopman AP 35.00 60011 10/28/2008 Richard Anthony Jimenez AP 5.00 60048 10/28/2008 Dylan B Dart -7 0 `v 1 ( { ., AP 15.99 60338 11/13/2008 Sandra Smith -- `,L: AP L(C� 9,450.20 60544 11/24/2008 PAULINE BECK � CZ AP Gl'� a 1 59.54 Sal 61118 01/06/2009 , Rodney W Morse AP 60.00 61606 02/06/2009 Class Act Uniforms S � Al' 208.00 61928 02/25/2009 Columbia Pacific AFS $ u) AP 157.50 62027 03/05/2009 Ariel Stefan Aurich AP 20.00 62154 03/12/2009 Roger Stover Wiley AP 0 O ng Co 60.00 62265 03/19/2009 Colorado Dept of Revenue Al' 0 3 -, 2 .70 62293 03/19/2009 Metropolitan Utility AP �� I� - 75.00 � 100.00 62311 03/19/2009 Sara Chacon 2 AP L L(c- (� I l 62349 03/23/2009- Bonita Court - 36 LLC V 7 r �'� �' AP / k- r. 0 08,428.56 (Y `1 CJ 62424 03/30/2009 California Pizza Kitchen Al' ,� ei r pt) 250.00 62536 04/06/2009 BinHost Technologies LLC AP I v v \> 48.00 62591 04/10/2009 Matthew Ryan McCarthy Al' L� 15.00 62647 04/10/2009 LeMay Mobile Shredding Al' V C 160.00 62774 04/16/2009 Jarret Gross AP 15.00 62857 04/30/2009 Corey Saffer PR 0.01 63009 05/07/2009 Paul William Vogel AP 25.00 63012 05/07/2009 Terrence Stephen Terry AP 25.00 63080 05/07/2009 Providence Occupational Health AP 175.50 63081 05/07/2009 Random House Inc AP 88.00 63087 05/07/2009 Group Mackenzie AP 100.00 . 63509. 05/22/2009 Demetria Corvallis Hunt AP 25.00 63515 05/22/2009 Terry Lynn Raybould AP 25.00 63879 06/16/2009 Victor Garcia Osorio AP 275.00 63998 06/26/2009 Warren Adolph Johnson AP 6.00 64017 06/26/2009 Erik Kyle Steen AP 25.00 64128 06/26/2009 J B & B CONSTRUCTION AP 5.90 64170 06/30/2009 Michael Barmache AP 25.00 Total $20,420.90 Total Checks: 41 BR - Checks by Date (03/21/2011 - 9:27 AM) Page 1 i a ° Building Division Request for Refunds TIGARI) TO: Phyllis Harris OK' I . FROM: Dianna Howse DATE: November 3, 2008 SUBJECT: Refund Requests for the week of 10/27/08 Please process the attached expenditure requests and return checks and this memo to me for disbursement: Refund Date Check Date Check Date of Case # or Refund Check Routed Mailed Payable To Receipt # Receipt Description Amount (Finance) (Building) Sandra Smith 2008 -669 2/29/08 PLM2008 -00078 $9,450.20 //t .. / i- � ""C SWR2008 -00020 / o7 / g . If you have any questions please contact me at x2430. Thank you. l: \Building\ Refunds \Administration \RouteCheckRequests.doc 01/16/07 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 I t MAL 'LiiTI,G,7•4 • November 26, 2008 Sandra Smith 0 - 12880 SW 121- Ave. Tigard, OR 97223 Re: Permit No. PLM2008-00078 & SWR2008-00020 Dear Ms. Smith: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: • Site Address: 12880 SW 121st Ave. Project Name: Smith Job No.: N/A Refund: El Check #60338 in the amount of $9,450.20. :I Credit card "return" receipt in the amount of $ El Trust account "deposit" receipt in the amount of $ Notes: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. If you have any questions please contact me at 503.718.2430. Sincerely, • • _ - Dianna Howse Building Division Services Supervisor Enc. \ Building \ Refunds \ Administration \ UrRefund-CancelPermitdot 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard-or.gov • TTY Relay: 503.684.2772 • CITY OF TIGARD RECEIPT 114 n . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 2008 -669 - 11/03/2008 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2008 -00078 Refund - [PLUMB] Permit Fee 245 - 0000 - 431000 $ -72.50 PLM2008 -00078 Refund - [TAX] 12% State Surch 100 -0000- 207020 $ -8.70 Total: $ -81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Other TAAA CONV 11/03/2008 $ -81.20 Payor: Total Payments: $ -81.20 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD RECEIPT n I:. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 2008 -669 - 11/03/2008 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID SWR2008-00020 Refund - [SWUSA] Sewer Connect 500 -0000- 207000 $- 2,800.00 SWR2008 -00020 Refund - [SWINSP] Sewer Inspec 245-0000-441001 $ -35.00 Total: $- 2,835.00 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Other TAAA CONV 11/03/2008 $- 2,835.00 Payor: Total Payments: $- 2,835.00 Balance Due: $0.00 Page 1 of 1 • 4 M ill61° T 7 City of Tigard April 14, 2011 Sandra Smith 12880 SW 121 Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 and SWR2008 -00020 Dear Ms. Smith: Our records show a refund check that was mailed to you remains outstanding and has not been submitted for payment. The check was delivered to you via the United States Postal Service and is referenced as follows: Site Address: 12880 SW 121 Ave. Project Name: Smith Check #: 60338 Amount: $9,450.20 Date Mailed: November 26, 2008 Note: Permit fees were refunded 100% as applicant was unable to connect to sewer as the elevation of the residential dwelling was too low to be servied by public sewer lateral. A voice mail message left at 503 -590 -3309 was not returned therefore this letter is mailed. Due to banking policies, this check is now invalid. Please contact me at 503.718.2430 to discuss your options. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 1:\ Building\ Refund4AZISN,'al - Wh hstaligatted ettigbrfP97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard- or.gov City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 • • m • . T I GARD. November 26, 2008 Sandra Smith 12880 SW 121st Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 & SWR2008 -00020 Dear Ms. Smith: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following. Site Address: 12880 SW 121st Ave. Project Name: Smith Job No.: N/A Refund: ® Check #60338 in the amount of $9,450.20. ❑ Credit card "return" receipt in the amount of $ • ❑ Trust account "deposit" receipt in the amount of $ Notes: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I:\ Building\ Refunds\ Administration \LtrRefund- CancelPemritdoc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772