Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
11 = Request Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • w . _•
TO: CITY OF TIGARD DEC 10 2014
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 CIl Y0ir rIGARD
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov 1ij1►IO1j
FROM: ❑ Owner [ Applicant 1 Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) G per� #C� T / t !T C
Mailing Address: P o ,So 1
City/State/Zip: O tQ CI ;(f,-
Phone No.: 5'61 G cjj ct t
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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: , � ao ILH c904-64
Site Address or Parcel#: Ia-a 5 S/ `M`t%/V S�
Project Name: T5t (-utiono(a t Sitdlc< Skop
Subdivision Name: Lot#:
EXPLANATION: .0 W/t er 4`t- L L€;(0447(o447 cct i4 ct 1 ro f
Signature: Date: f fad A/
Print Name: O$ {=D, (— / .0i9 /,2O,01) = .gyp .erb
Refund Policy / .� ' /VI 3, ro o
./
1. The Community Development Director or Building Official may authorize the refund of. /3/ r0
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 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 B
Refund Processed: Date f;zp`/'/y By Invoice Processed: Date By
Permit Canceled: Date /,2/i� �y By Parcel Tag Added: Date _ By
Receipt# Date Method Amount$
I:\Building\Forms\RegPemritAction_062614.doc
i _
TIGARD
City of Tigard
December 18, 2014
Oregon Heating&A/C
Attn: Josh Foster
PO Box 241
Dundee, OR 971115
Re: Permit No. ELR2014-00264
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12215 SW Main St
Project Name: Taekwondo & Smoke Shop
Job No.: N/1
Refund Method: r✓ Check#215934 in the amount of$134.40.
❑ Credit card"return" receipt in the amount of$ .
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$ .
Comrnent(s): Per applicant's request as owner of building cancelled job. Refund 80%
of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Z,/ . -ql, ,
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 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: Oregon Heating&A/C DATE: 12/11/2014
Attn: Josh Foster
PO Box 241 REQUESTED BY: Dianna Howse
Dundee, OR 97115
TRANSACTION INFORMATION:
Receipt#: 198401 Case#: ELR201-E-00264
Date: 11/13/2014 Address/Parcel: 12215 SW Main St
Pay Method: CreditCard Project Name: Taekwondo& Smoke Shop
EXPLANATION: Per applicant's request as owner of building cancelled job. 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 fees 220-0000-43103 $120.00
12% State Surcharge 100-0000-24001 14.40
TOTAL REFUND: $134.40 I�
APPROVALS: SIGNATURE.-DATE:
If under$5,000 Professional Staff LJ'/,_
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: I 42/41-7/y iy ByrL,�
1:\Building\Refunds\RefundRequest.doc x 09/01/2010