Correspondence 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 for Permit 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: Columbia Heating& Cooling DATE: 3/31/2014
Attn: Marlena Meedom
PO Box 230397 REQUESTED BY: Dianna Howse
Tigard, OR 97281
TRANSACTION INFORMATION:
Receipt#: 195318 Case#: MEC2014-00133
Date: 3/21/2014 Address/Parcel: 13165 SW Laurmont Dr.
Pay Method: CreditCard Project Name: Packard
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
Mechanical permit 230-0000-43102 $72.00
12% State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff 4_,'("t//7/7:7c.,"?-(-
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 ,?/5 i//% By: ) 7/
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Request for Permit Action MAR 2 4 2014 3��
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TO: CITY OF TIGARD CITY OF TIGARD
Building Division Services Coordinator BUILDING DIVISION
13125 SW Hall Blvd,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 .tigard-or.gov
FROM: ❑ Owner VAppricant Contractor fl City Staff
(check one)
REFUND OR Name: '
INVOICE TO: (Business or Individual) is . !• • A ■ glii .l k tit I
1
Mailing Address: I! '40, +
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City/State/Zip: /_i i
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Phone No.:
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(i):
21/CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt,if available). .
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
[] REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit#: `
Site Address or Parcel#! 1 3 I(L)5 11:1llailanf-aC----
Project Name:
Subdivision Name: _ Lot#:
, _10A.e_ /
EXPLANATION: - r<IJr
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Signature: Date: 5.-aq-- 14-
Print Name: �G-Gur4A 7 IZFT$1^/ /f,et
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Refund Policy
1. The Director or Building Official may authorize the refund ol_ P-ry - (p y/ 020 • /4
a) any fee which was erroneously paid or collected.
b) not more than 80°:of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permit&
d) not more than 80%of the budding plan review fee when an application is canceled before any plan review effort has been expended.
c) not mon than 80%of the building permit fee for issued permits poor to any inspec°On requests_
2. Refunds w01 be returned to the ominal Payer in the came method in which payment was received Please allow 1-2 weeks for processing refunds.
1'c)IR 01 I ICI. l `,l: c)N1-'
Rte to S•s Admix: Date By Rte to Bl••Admix: Date 3Afigrag irff�
Refund Processed: Date 3 3/ / B _0%0 Invoice Processed: Date B
Pemrit Canceled: Date An 13' ./A Parcel T _Added: Date B.
Receipt# Date Method Amount$
T;\Suildrng\Forrris\RegPerrratA rL Rev 07 26/07