PFI2014-00002 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.tigud-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name: The Circuit Inc.
INVOICE TO: (Business or Individual)
Mailing Address: 6050 SW Macadam Ave
City/State/Zip: Portland, Oregon 97239
Phone No.: 503-866-6020
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
VOID PERMIT APPLICATION.
REFUND ERMIT 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#: PFI2014-00002
Site Address or Parcel#: 16255 Upper Boones Ferry Road
Project Name: The Circuit SW ii bouldering gym
Subdivision Name: Lot #:
EXPLANATION: Refund of assurance to construct public improvements.The public
improvements have been completed and accepted.
Signature: Z40-A
Date: August 19,2014
Alfie ickman
Print Name:
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b) not more than 80°/o of the land use application fee when an application is withdrawn or canceled before any renew effort has been expended.
c) not more than 80%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 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 Svs Admin: Date By Rte to _ldtrun: Date ZMY B
Refund Processed: Date -?AF11Y-?A1Invoice Processed: Date B
Permit Canceled: Date By Parcel Tag Added: Date B
Receipt# Date Method Amount$
1:\Building\romts\RLgPcrtnitAction_0G2G 14.doc
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City of Tigard
September 18, 2014
The Circuit Inc.
6050 SW Macadam Ave.
Portland, OR 97239
Re: Permit No. PF12014-00002
Dear Applicant:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address: 16255 SW Upper Boones Ferry Rd
Project Name: The Circuit
Job No.: N/A
Refund: ® Check #215001 in the amount of$7,600.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account "deposit" receipt in the amount of$
Notes: Refund of customer cash assurance for public improvements completed.
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
A-A City of 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 RequestforPetmitAction 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: The Circuit Inc. DATE: 9/10/2014
6050 SW Macadam Ave.
Portland, OR 97239 REQUESTED BY: Dianna Howse
AD
TRANSACTION INFORMATION:
Receipt#: 195349 Case#: PFI2014-00002
Date: 5/1/2014 Address/Parcel: 16255 SW Upper Boones Ferry
Pay Method: Check Project Name: The Circuit
EXPLANATION: Per PCL'/engineering request as public improvements have been completed and
accepted.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Customer Deposit 100-0000-22000 $7,600.00
TOTAL REFUND: $7,600.00
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
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONL
Case Refund Processed: F Date: /4 / B :
l:\Building\Refunds\RefundRequest.doe x 09/01/2010