Permit Feb 10 2015 5: 14PM Bridgetown Electric 503-621 -7123 page 1
City of Tigard • COMMUNITY lwvlLI.013M :NT ut.:PARTNIRiE
CEI VP in
1,11 • Request for Permit Action F
l', ..i.1.1 13125 SW Hall Blvd. •• Tigard,Oregon 97223 • 503-718-2439• www,tt r(l�oi'. '/5
LI1Y
10. CITY OF TIGARD BUILDING D�GARD
Building Division ICION
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPer[nits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant leKontractor ❑ City St f
check.(1)our , 0, r ,
REFUND OR Name: // //// �,�.
INVOICE TO' tl;mmi...,r Irdinadual) _ ! t'/1g AJ Y.Alee/�/ °L ����
Mailing Address: C7 )/ /4' • yeRvigitv $
City/State/Zip: 7eriZAMI Og 97-445 _
Phone No.: 03 e2/ '7/Z
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
79 ANCEL/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).
[j REMOVE/RF.PI ACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: �4.R 217// ' O)21
Site Address or Parcel #: /g,j S .IA) 7 IA° s /es-
Project Narne: xis //ik f-zea✓/P
Subdivision Name: Lot#:
EX LA/j NATION: + iesl`P p - ,- i..< .r.,n EAR 20/y,Da2,2_
Signature: Date: 2./s1'7D/S'
Print Name: 'PA/LS eis!/Al
Refund Policy
I. The city's Community Development Director,Building Official or City Engineer ma)authotvc the refund of
• Any fee which was erroneously paid or collected.
• Not more than SIP/o of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued perm its.prica to any in'pectins requests' "6-74-/- l
2. All refunds will be returned to the original payer in the form of a check via US postal service. �06 A/
3. Please allow 3-4 weeks for processing refund mtluests. 72'ef) — 6e . CV = /S
f oi: (it::l'i('E I tit:O'.1..`i
Brute to S s Admin: Date 1,fliaM,�B.� Route to Records: _Darr, G L� M%:
Refund Processed: Date Invoice Processed: Date By
Permit Canceled: �AMiall3°n%•allIll Pacce7 Added: Date B
I:\l)utklalg\l urr.ts\Reeermit:lcuon l 12)14.'oc
T I GARD
City of Tigard
February 26, 2015
Bridgetown Electric
Attn: Davis Cain
5701 N Lombard St
Portland, OR 97203
Re: Permit No. ELR2014-00268
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13535 SW 72"d Ave., Ste. 165
Project Name: EPIS Inc Prewire
Job No.: N/A
Refund Method: ® Check#216549 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 permit was a duplicate (see ELR2014-00232).
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 fir Perrlut_-1 tion 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: Bridgetown Electric DATE: 2/19/2015
Attn: Davis Cain
5701 N Lombard St REQUESTED BY: Dianna Howse
Portland, OR 97203
TRANSACTION INFORMATION:
Receipt#: 198436 Case #: ELR2014-00268
Date: 11/18/2014 Address/Parcel: 13335 SW 72nd Ave.,Ste 165
Pay Method: CreditCard Project Name: EPIS Inc Prewire
EXPLANATION: Per applicant's request as permit was a duplicate of ELR2014-00232. Refund 80%of
permit fee.
REFUND INFORMATION:
Fee Description From Receipt_ Revenue Account No. • Refund
Example: Building Permit Fee Example: 2300000-43104: $Amount
Restricted energy permit fee 220-0000-43103 $60.00
12% State surcharge 100-0000-24001 7.90
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES DATE:
If under$3,000 Professional Staff
If under$12,500 Division Manager
If under$23,500 Department Manager
If under$30,000 City Manager
If over$30,000 Local Contract Review Board
-FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: _ Date: ,;2/,.2.4,/,(.5" By: —
I:\Building\Refunds\RefundReyuest.dnc x 09/01/3010