Permit 04/28/2014 10:20 FAX 5036513345 BENS-HEATING&AIR QJ 002
IIICITY OF TIGARD ELECTRICAL RESTRICTED ENERGY PERMIT
s-, COMMUNITY DEVELOPMENT Permit lk: ELR2O14-00079
T I c'A it ) 13125 SW Hall Blvd.,Tigard OR 97223 503,718.2439 Date issued: 03/2512014
Parcel: 28103AC05800
Jurisdiction: Tigard
site address: 12621 SW 113TH PL
Project: Llday Subdivision: HUMBOLDT CREEK ESTATES Lot: 9
Prof ct Description: Reconnect as furnace
Reconnect AC
Contrao or. BEN'S HEATING&AIR CONDITIONING LLC Owner: LIDAY,GARRY F&LOUISE A REV LI
PO BOX 9 BY LIDAY,GARRY&LOUISE TRS
WEST LINN.OR 97068 12821 SW 113TH PL
ItGARD,OR 97223
PHONE: 503-233-1779 PHONE:
FAX: 503-851-3345
FEES
Description Date Amount
Sp,r ,lflCS:, Restricted Energy Permit OW2512014 $75.00
12%State Surcharge-Electrical 03/25/2014 $9.00
Type of lse: SF
Class o ork: ALT
Total Nt?rlber of Systems:
Audio& itsren' N
Security Ilarm' N
Garage oor Opener: N
HVAC
Vacuum System: N
Other: N
Other Disc: _J' Total $84-00
/`\ ,('� Required Items and Reports(Conditions)
c-sajt
This permit It Issued subject to the regulations Contained in the Tigard Municipal Code. Siete of OR. Specialty Codes end all other epplicsbio law, All work wilt
be done in a:cordance with approved plane. This permit will expire If work is not started within 180 days of issuance. or IT work la suspended for more the 180
days. ATTEr'fION: Oregon law requires you to fellow the rules adopted by the Oregon Utility Notification Center. Those rules are get forth in OAR
962-001-0010 trough OAR 952-001-0095 You may obtain a Copy of the rules or direct Questions to OUNC by Coifing 503.232.1987 or 1.800 332,2344.
Issued By Permlttee Signature:
OWNER INSTALLATION ONLY
The mite! lion is being made on property I own which if not intended for 5515.lease or rant
OWNER'S-JGNATURE: Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURI OF SuPR,ELEC' Date:
LICENSE N
Call 803,639.4175 by 7!00 a.m.for the next available inspection data.
This penult card shell be Kept in•Conspicuous piece on the job site until completion of the project
Approved plans are required on the Job■tts■t the time of°soh inspection.
04/28/2014 10:20 FAX 5036513345 BENS-HEATING&AIR 0003 CC' 11y.
City of Tigard • COMMUNITY DEVELOPIt 4T T11E N cile
:1 ■ Request Permit Action
r ;,,1:.1) 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.71 8.2439•www.tigard-or.gov
T ): CITY OF TIGARD �� l
Building Division Services Supervisor l
R EcE 13125 SW i Iall Blvd.,Tigard,OR 97223 ,.
_
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov APR 2 8 2f
FROM: El Owner [ Applicant rg3 Contractor EOI A�ln(duels one) , .lc
r
gu I ,
RsFIJND OR Name: 'n
Il"VOICE TO: (Business or Individual) 1� 1��+,-;Y1 c 1/C0..—.
Mailing Address: eR C7 C44_ q
City/State/Zip: \22 ,E L;r.ri cl--. CA 90719
Phone No.: 50-6- 9- - \--).-)q
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
E INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
C REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: E(:TN c OI LI -0 Q 0l ci ,
Site Address or Parcel#: ` LQ @ 1 �lA) ` 1 r26-1.h PI
Project Name: L.--.t( CL\., ZNr\ cq.,A 1 T
Subdivision Name: Lot#:
E) PLANATION: - \,JC� ■O OO`,Jc-,S2 --Oh0`,L O V\
e_-,e_ `C N CG C,.i.-, Wes`. Yl42,..e.cLe_a. be.)!' +, \YN.c �A1 -
----c\r\ 2 eJt4_c_-Ir-rSCi Cyr, � f■.\1S WI 0W Y1 R-Q-irr \11.-5'
Signature: kl\ c1 G--- Date: Ll I a J f( i
Prat Name: �cyeGir 0, y.. -,,\c.o.a 7� 9 !J 1 S `l, �'
Re Policy �� IS f- t .. /6. ft'
1. to Director or Building Official may aut oei w the refund of: (O o- 7.,2 a-
a) any fee which was erroneously paid or collected, /2,6-r-2('VG. 67..2-0
h) not more than 80°/,of the land use application fee when an application is withdrawn or canceled before any review effort has bean expended.
c) not more than 80%of the land use application fee for issued permits.
. nut 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 530%of the building pcnmr fcc for issued permits prior to any inspection requests.
2. R funds will be returned to thr:original Payer in the same rrwthod in which paymtan was received. Please allow 2-4 weeks For processing refunds,
I OR t)J 1 ICI, ( ',I . ()\I \
Rte o S s Adnxin: Date , r EM D. A . , Rte to Bl i:Adtnin: Date _ _ and t n%.--
Refind Processed: Date .flaM011134. 411 Invoice Processed: Date B
Permit Canceled: Date S d' /y By _;./-' Parcel Tag Added: Date By
Reekipt# Date f Method Amount$
I;\BLIding\Itortrts`ReciPemriuluitm.tk c Rev 05/25/2012
04/28/2014 10:20 FAX 5036513345 BENS-HEATING&AIR Z001
BEN'S>-
Heating & Air Conditioning LLC
PO Box 9
West Linn, OR 97068
E-Mail: phaedra @bensheating.com
Office: 503-233-1779 Fax: 503-655-2286
CCB#64597
Da te: 0'6 l y # of pages: 3
Tot@!i ob o c- � (c c
Fax: 5 59S- o
ATFN: C\tvc\ri.u...ri\s,% rn k _,z '`.(--4-vy cir ._
1 w \ b.-A4\ P1. ; t c t.
Er
TIGARD
City of Tigard
May 8,2014
Ben's Heating&AC
Attn: Phaedra Dibala
PO Box 9
West Linn, OR 97068
Re: Permit No. ELR2014-00079
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12621 SW 113`h P1
Project Name: Liday
Job No.: N/A
Refund Method: ❑ Check# in the amount of$ .
® Credit card "return" receipt in the amount of$67.20.
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
n Trust account"deposit" receipt in the amount of$ .
Comment(s): Per applicant's request as electrician was required. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,Z,-) ilk: , -
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
7IIII
1°' 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: Ben's Heating&AC DATE: 4/29/2014
Attn: Phaedra Dibala
PO Box 9 REQUESTED BY: Dianna Howse
West Linn, OR 97068
TRANSACTION INFORMATION:
Receipt#: 195352 Case #: ELR2014-00079
Date: 3/25/2014 Address/Parcel: 12621 SW 113th P1
Pay Method: CreditCard Project Name: Liday
EXPLANATION: Per applicant's request as electrician is required. 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: SIGNATURES DATE:
If under$5,000 Professional Staff I '�'� c de—
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: I Date: .5,4//y By: _ :
1:\Building\Refunds\RefundRequest.doc x 09/01/2010
I_