Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ',,I
01 Re t for Permit Action
, FEB , 01 TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • Au .!:_:-•st• •I'OF'TIGARD
I,DI140 DIVISION
TO: CITY OF TIGARD
Building Division V 0
13125 SW Hall Blvd.,Tigard,OR 97223 (o� =/a
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-6r.gov
FROM: ❑ Owner ❑ Applicant NI Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: MCCC (.:66..„-LArIv j/,
INV OICE TO: �"su'ess or Indittidual) ( (I ec (�
Mailing Address: 01 `� 6 tj `�1 AVel
City/State/Zip: r ' IAA I O C `1 -
Phone No.: 503 . a, 0 - i sal
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/RF,PLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: LG 7Di - OCC96,2
Site Address or Parcel#: 1 D(13-7 a $u3 o1ory___) NQ,I ► l/ Way
Project Name:
Subdivision Name: Lot#:
EXPLANATION: OntUl O\ m}r a k aloe 1 Wet /
ui
Signature: AO i I _ Date: 2.:(1 • I
Print Name: I,vnpi'ri�r(1ivar
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 permits prior to any inspection requests. / r/‘,ld /267-fiin/i55
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests. 9e. e// — f/p 7, 7S = 3- c�� 6 /
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FOR OFFICE USE ONLY _
Route to Sys Admin: Date By Route to Records: _ Date , /5 B,1 •
Refund Processed: _Date...2/24i s By 4( Invoice Processed: Date By
Permit Canceled: Date/ B;fr.. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0192314. oc
TIGARD
City of Tigard
February 26, 2015
McCoy Electric
Attn: Jana Hammer
2014 SE 9th Ave.
Portland, OR 97214
Re: Permit No. F1,C2014-00682
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10670 SW Black Diamond Way
Project Name: Kinsey
Job No.: N/A
Refund Method: ® Check#216583 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 minor label was applied. 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
-311 . 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: McCoy Electric DATE: 2/19/2015
Attn: Jana Hammer
201.1 SE 9th Ave. REQUESTED BY Dianna Howse
Portland, OR 97214
TRANSACTION INFORMATION:
Receipt#: 193382 Case#: ELC2014-00632
Date: 12/01/2014 Address/Parcel: 10670 SW Black Diamond Way
Pav Method: CreditCard Project Name: Kinsey
EXPLANATION: Per applicant's request as only a minor label was needed. Refund 80%a of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electric permit fee 220-0000-43103 $62.75
12% State surcharge 100-0000-24001 7.53
TOTAL REFUND: $70.28
APPROVALS: SIGNATU$ES/DATE:
If under$5,000 Professional Staff
If under$12,300 Division Manager
If under$25,300 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE O Y
Case Refund Processed: Date: p -,//s By: /
is\Building\Refunds\RefundRequest.doc x 09/01/2010