PFI2011-00027 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
= Request Permit Action
13125 SW Hall Blvd. - Tigard, Oregon 97223 - 503.718.2439 - www.tigard-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
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:
INVOICE TO: (Business or Individual) fU-D k f,.{T-,e— kTTN, ;ZArHY 0TE. 04002/3S'o
Mailing Address: 38 as 5 F— ZZ•` Auk-
City/State/Zip: fr'L172_ 7 2_0 2—
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
CANCEk71Y1OID PERMIT APPLICATION.
REFUND RMIT FEES (attach copy of original receipt and provide explanation below).
CE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: PF r 7,0 I( — D O 0 Z-7
Site Address or Parcel#: ! G S 4--J Al oc- t4e-j r.
Project Name: (M 1-t1AjA-- P—C
Subdivision Name: Lot#:
EXPLANATION: R£f-UNb CA.->,q Fox- !ti= 9-oma-'
Soc�00 �c1c.Pr� lt�s4�-6
IduL�v`��a , ux1YLK QdP�f�T� A*bt-r�s� rte;
Signature: Date: ! / ��-
Print Name: J14 19 C- LJ K l m
Refund Policv
1. The Community Development 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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
e) not more than 80°.'a of the land use application fee for issued permits.
d) not more than 80°'0 of the building plan review fee when an application is canceled before any plan retiew effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to admin: Date Q / B,
Refund Processed: DateflW71—Y By Invoice Processed: Date B
Permit Canceled: Date B —Parcel Tag,added: Date B
Receipt# Date Method Amount$
1:\Building\Pones\Req PennitAetion_062614.doe
4
City of Tigard
September 18, 2014
Kroger
Attn: Kathy Lite 04002/350
3800 SE 22"'Ave
Portland, OR 97202
Re: Permit No. PFI2011-00027
Dear Ms. Lite:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address: 11565 SW Pacific Hwy
Project Name: Fred Meyer
Job No.: N/A
Refund: ® Check #214959 in the amount of$5,000.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account "deposit" receipt in the amount of$
Notes: The check was sent separately for refund of customer cash assurance for work
completed in the right-of-way.
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 0 www.tigard-or.gov
VM
City of Tigard
FA--. b 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 far PernaitAction 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: Kroger DATE: 9/10/2014
Attn: Kathy Lite 04002/350
3800 SE 22nd Ave REQUESTED BY: Dianna Howse
Portland, OR 97202 1�IW
TRANSACTION INFOIUMATION:
Receipt#: 185446 Case#: PFI2011-00027
Date: 2/7/2012 address/Parcel: 11565 SW Pacific Hwy
Pay Method: Check Project Name: Fred Nfeyer
EXPLANATION: Refund cash assurance for work in right-of-way completed and approved.
REFUND INFORhIATION:
' Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Exam Ie: 2300000-43104 $Amount
Customer Deposit 100-0000-22000 $5,000.00
TOTAL REFUND: $5,000.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
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
----F-OR TIDEMARK SYSTEM ADMINISTRATION-USE ONLY
Case Refund Processed: Date: / By:
I:\Building\Refunds\RefundReyuest.doc s 09/01/2010
City of Tigard * COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action
13125 SW Hall Blvd. - Tigard, Oregon 97223 - 503.718.2439 - WWW.ti arg d-or. ov
TO: CITY OF TIGARD
Building Division Services Supervisor
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:
INVOICE TO: (Business or Individual) fiZ" Ao,,oe- ATTN.— j4ar Y L1 Tt 04W2-1 3S-D
Mailing Address: 38070 S C 2-Z 4. /fug.
City/State/Zip: 0012-T,-" 6-x._ e 7 2-0 L--
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ 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 #: PF 1 yU N - 6 0 0 Z7
Site Address or Parcel #: U5'65- P/{t-I f1C. f4W`-,
Project Name: 144 9-`f�%n-- P—C- iy�
Subdivision Name: Lot #:
EXPLANATION: 12F-Fut--D CA--i,q 12o+,-1
Ayxx-IAWb +> fLf- A4ci�Rt- P12Z ; ,O&) crcPr les4446
Signature: Date:
Print Name: 1")Fy i rl?
Refund Policy
1. The Community Development 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 800.16 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. All refunds will be returned to the original payer in the form of a check Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date I B Rte to Bldg admin: Date B
Refund Processed: Date By Invoice Processed: Date B
Permit Canceled: Date By Parcel Ta added: Date B
Receipt# Date Method Amount$
1:\Bui(ding\Forms\RegPermit r\ction_062614.doc
CITY OF TIGARD RECEIPT
a
s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 185446 - 02/07/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12011-00027 PFI Permit Fee 100-0000-43114 $4,950.00
PF12011-00027 Erosion Control Permit 100-0000-22002 $40.00
PF12011-00027 Erosion Control Plancheck-ENG 100-0000-43107 $13.00
PF12011-00027 Erosion Control Plancheck-CWS 100-0000-22003 $13.00
PF12011-00027 Customer Deposit 100-0000-22000 $5,000.00
Total: $10,016.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 4421495 KPEERMAN 02/07/2012 $10,016.00
Payor: KROGER
Total Payments: $10,016.00
Balance Due: $0.00
Page 1 of 1