Permit Apr. 23. 2014 3: 24PM No. 0757 P. 1 e (i
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \i/
711 1, Request Permit Action yA9/,y
T 1(_,A RD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.
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TO: C I TY OF TIGARD � �,,Q
Building Division Services Supervisor An 2 3 2
13125 SW Hall Blvd.,Tigard, OR 97223 . efr ct6KCID
Phone; 503.718.2430 lax: 503.598.1960 www-tigard-or.gov 011 111 P
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FROM: ❑ Owner ❑ Applicant ® Contractor ❑ City MP
(check one)
REFUND OR Name: ADT LLC
INVOICE TO: (Business or Indmdual)
Mailing Address: 7989 SW Cirrus Dr •
City/State/Zip: Beaverton, OR. 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (1):
❑ CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELR2013-00300
Site Address or Parcel#: 12000 SW Main St
Project Name: Sierk Orthodontic
Subdivision Name: Lot#:
EXPLANATION: Customer cancelled install
•
Signature: VhGr Date: 4/23/14
Print Name: Lori McMurphy 2 re D 9•ct So77 2-e7 -/ [
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Refund Policy ----I------ '—
1. The Director or Building Official may authorize the refund of: &Pe!.re e- 7 /5 /.efC)
a) any fee which war erroneously paid or collected. -1". 67. 02() .. (G • kQ
b) not more than SO%of the land use application fcc when en application is withdrawn or canceled before any review effort has been expended.
c) not more than SO%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 SO%of the building permit fcc for issued permits prior to any inspection requests.
2. Refunds will be returned to the onginal Payer in the same method in which payment was received Please allow 2-4 weeks for processing refunds.
Rte to Sys Admin: Date 9 673 /y B Rte to Bldg Admin: Date y Jr/V By
Refund Processed: Date /24+// Bv,?/ Invoice Processed: Date By
Permit Canceled: Date y/19' /y By Parcel Tag Added Date By
Receipt# Date / Method Amount$
h\Building\Forms\RegPermitAction.doc Rev 05/25/2012
Apr. 23. 2014 3:24PM No. 0757 F. 2
CITY OF TIGARD RECEIPT
IN"f: 13125 SW Hall Blvd.,Tigard OR 97223
. — 503.639.4171
Tr ;tt. 0
Receipt Number: 194034 - 11/2112013
CASE NO. FEE DESCRIPTJQ1 REVENUE ACCOUNT NUMBER PAID
ELR2013-00300 Restricted Energy Permit 220-0000-43103 $75.00
ELR2013-00300 12%State Surcharge-Electrical 100-0000 24001 $9.00
Total: $04.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DEM RECEIPT AMT
Credit Card 031232 PUBLICUSER107 11/21/2013 $84.00
Payor: MaryAnn D'Angelo
Total Payments: $64.00
Balance Due: $0.00
•
Page 1 of 1
TIGARD
City of Tigard
May 8, 2014
ADT LLC
Attn: Lori Murphy
7989 SW Cirrus Dr.
Beaverton, OR 97008
Re: Permit No. ELR2013-00300
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 1200 SW Main St
Project Name: Sierk Orthodonics
Job No.: N/A
Refund Method: ❑ Check# in the amount of$
® Credit card "return" receipt in the amount of$67.20.
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$
Comment(s): Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
IN IN
. City 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: ADT LLC DATE: 4/29/2014
Attn: Lori Murphy
7989 SW Cirrus Dr. REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 194034 Case#: ELR2013-00300
Date: 11/21/2013 Address/Parcel: 1200 SW Main St.
Pay Method: CreditCard Project Name: Sierk Orthodonics
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Restricted Energy Permit 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATU 'FS/DATE:
If under$5,000 Professional Staff 4
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„
- 2 Case Refund Processed: Date: I - V'% I By: I ,1
1:\Building\Refunds\RefundRequest.doc x 09/01/2010