Permit Sep. 15. 2014 3:49PM No. 1292 P. 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \J 0 1 Dl
311 : _. Re q uest Permit Action /%3/fy
TIGARD, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO CITY OF TIGARD RECEIVED
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 wvvw.tigard-or.gov SEP 15 2014
FROM: El Owner ® Applicant IS] Contractor
❑ Cit, ;J�If OF TIGARD
(cheer one) BUILDING DIVISION
REFUND OR Name: ADT LLC
INVOICE TO: (Business or individual)
Mailing Address: 7989 SW Cirrus Dr
City/State/Zip: Beaverton, OR. 97008
Phone No.: 503469-7241
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#: ELR2014-00083
Site Address or Parcel#: 15717 SW 74d'Ave #450
Project Name: State Serve
Subdivision Name: Lot#:
EXPLANATION: Customer cancelled the burglar alarm/cctv installation
Signature: _� C Date: 09/15/2014
Lori McMurphy
• A'€ /A T. f./
Print Name: _ /s-,
1. The Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected. 6'7.AO /64V
V
b) not more than 80"/r of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 805/0 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.
t) nor more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date id /3 iY By
Refund Processed: Date/03//r/ B • Invoice Processed: Date By
Permit Canceled: Dare /0//3//y By Parcel Tag Added: Date By
Receipt-# Date Method Amount
I:\Building\Forms\RegPermitAction_doc Rev 05/25/2012
TIGARD
City of Tigard
October 13, 2014
ADT LLC
Attir. Lori-McMurphy
7989 SW Cirrus Dr.
Beaverton, OR 97008
Re: Permit No. ELR2014-00083
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15717 SW 74th Ave. #450
Project Name: State Sery
Job No.: N/A
Refund Method: ® Check#215156 in the amount of$67.20.
❑ Credit card"return"receipt in the amount of$
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,
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 forPermit 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: 10/2/2014
Attn: Lori McMurphy
7989 SW Cirrus Dr REQUESTED BY: Dianna Howse
Beaverton,OR 97008
TRANSACTION INFORMATION:
Receipt#: 195396 Case#: ELR2014-00083
Date: 3/28/2014 Address/Parcel: 15717 SW 74th Ave. #450
Pay Method: CreditCard Project Name: State Sery
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: 2300000-43104 $Amount
Electrical permit 220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATUR, D TE:
If under$5,000 Professional Staff 4.1764
i
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: Date: /d /3 <V By: *War
I:\Building\Refunds\RefundRequest.doc x 09/01/2010