Correspondence IN IN
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request forPermit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: ADT LLC DATE: 3/31/2014
Attn: Lori McMurphy
7989 SW Cirrus Dr. REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 194081 Case#: ELR2013-00306
Date: 11/26/2013 Address/Parcel: 12035 SW Pacific Hwy
Pay Method: CreditCard Project Name: Brake Force
EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIG • - b RES/DATE:
If under$5,000 Professional Staff / r1C__
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
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: I ,3/3//y I By: /
1:\Building\Refunds\RefundRequest.doc x 09/01/2010
e._, ...Feb. 18.,..2014910;47Ah EQ5981.960 CITY OF TIGARD NO, 0408 P. ,_1• 02/02
Feb, 1 7. 2014 :30AM Na. 0401 P. 1 Pc �t/ P1
City of f Tigard • COMMUNITY DEVELOPMENT DEP• •TMEN'P 10 v t 1
IOC \JO r
w Request Permit Action
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a , F.Ft 13125 SW Hall Blvd, •Tigard, Oregon 97223 •'503.718.2439 •www.ti at . ov J
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To- CITY OF TXGAB.D ' $/ T1-Op , ���¢
Building Division Services Supetvisot 0f1�r. 1C4.1e
13125 SW Hail Blvd.,Tigard,OR 912X3 Oft y .9
Phone! 303.718.2430 Fax: 503.598.1960 warw.dgard-or,gov ok
PROM: ❑ Daman ❑ Applicant ® Conuactot El City Staff
(tear ox)
REFUND OR Name: ADT LLC
INVOICE TO: (BUEinesa Cr Iadiidu4
Mailin8 Address: 7989 SW Circa Dr
City/State/Zip: Beaverton,OR. 9700B _
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT PEES (an ch copy of original receipt and psov.de explamtdon below).
El INVOICE FOR FEES an(attach case fee schedule and provide exltlarlation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ELR2013-00306
Site Address or Parcel#: 12035 SW Pacific Hwy
Project Namel Brake Force
Subdivision Name: - Lot#:
EXPLANATION: Customer cancelled install
* Signature: _J.,_ Date: 2/14/14
Lori McMurphy
Print Name: AI/ 60 , /ler&,../ /S.ct
IteLnd?olio .as 4(Pa
1. The 4ireaor or Building Official rmr auchodae the 1-efitnd of 4.7. AO /e •Fa
a) any fcc which war erroneoudy paid or collected.
b) net meat than litY4 ache land um applieaoon fcc when an appiicauan is:withdrawn or canceled before any review efface hu been upended
r) flee room&tan 80iio of the load sore app of oe fcc for timed peon*
d) not more than Bier.of rho building glen skew fee When xr,applacaion iy ranceIed before slay plan renew effort lea been eapwtded.
o) net mote dean So'.atilt 1:lu7Wing panic fee for it:ued pecniv prior re any icupeeden reeueetc.
2. Refwuir wib lm=mid to the ociginaJ Pales m the same method in which pry nenr way received.Please allow 2.4 weeks for processing refunds.
OI- OFl-I(_.: 1.'.51-± ( \L 2
Rte toS'sixchoio: bate ..glarlINr 9 Ate roBl•:Admin: Dare ...3 4WASIOrrallral_
Refund Processed; Date 3 Alli' lcm Invoice Processed: Date B
BEM. Date MA • .0 v Parcc1 T :ridded; l)Dt -
Dare Method Amount S
I,9Land:rosTornelRe9pecrricAcdon.dee Act 03/29/2012