Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V ay'
11 II
Request Permit Action
l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 •www.ti
IVEp
TO: CITY OF TIGARD SEP
Building Division Services Supervisor L 0 2014
13125 SW Hall Blvd.,Tigard,OR 97223 tin ofTICARU
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov RUILDIN
G"ZION
FROM: ❑ Owner ❑ Applicant J Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) Z-Ohn sP-n L L CE"G I I'l.
Mailing Address: i COS(061 J LO (.05-t1-7 Ave_ -4 3
City/State/Zip: Lake,e, o Std Q D q e (p3 s-
Phone No.: 603) f -2.50
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
4 '�10 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#: (,{C.-2—D114—009 L.{rj
Site Address or Parcel #: I (A l Stc 'PGA-C-If C-
ProjectName: U 10n CGOSpe\ 11Yliss1olr>
Subdivision Name: I Lot#:
EXPLANATION: Sub C AA 1 CLI I e
Signature: �/ J Date: 01 I I 4
Print Name: Ch�(11 U-11Seel / Ccc.v� /1-670-/A/
Refund Policy 7O ,y g !° •7� - /5:67
1. The Community Development Director or Building Official may authorize the refund of: 9 1f f - 7, 53 (P.i
b) any fee which was erroneously te land paid application app any vie tel �� ?
b) not more than SD%of the lead use lication fee when an application is withdrawn or canceled before an re e ort en e �
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.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date/,e apy By
Refund Processed: Date/p,//. //V By,: &. Invoice Processed: Date By
Permit Canceled: Date/dlj //y B ter. Parcel Tag Added: Date By
Receipt# Date '7 Method Amount$
I:\Building\Forms\RegPennitAction_062614.doc
� 1
TIGARD
City of Tigard
October 13, 2014
Johansen Electric Inc.
Attn: Charlynn Leifsen
16869 SW 65th Ave., #311
Lake Oswego, OR 97035
Re: Permit No. ELC2014-00445
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11611 SW Pacific Hwy
Project Name: Union Gospel Mission
Job No.: N/A
Refund Method: ® Check#215193 in the amount of$70.28.
❑ Credit card"return" receipt in the amount of$
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,
r Amp
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
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 fbr 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: Johansen Electric Inc. DATE: 10/2/2014
Attn: Charlynn Leifsen
16869 SW 65th Ave,#311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 197180 Case #: ELC201-1-00445
Date: 8/12/2014 Address/Parcel: 11611 SW Pacific Hwy
Pay Method: CreditCard Project Name: Union Gospel Mission
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: 230000043104 $Amount
Electrical permit 220-0000-43103 $62.75
12%State Surcharge 100-0000-24001 7.53
TOTAL REFUND: $70.28
APPROVALS: SIGNATUR •ATE:
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 ONLY
Case Refund Processed: I Date: I ./e/i3` y By: I •1129}2
(:\Building\Refunds\RefundRequestdoc x 09/01/2010