Permit Feb. 23. 2015 9:22AM No. 0781 P. 5
1 0
City of Tigard • COMMUNITY DEVELOPMENT DEPART)
RECEIVE')
Re q it Action
i 1, ., ; 1, 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigs o4 9 015
CITY OF HOARD
TO: CITY OF TIGARD BUILDING DIVISION
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner 7<lApplicant ❑ Contractor ❑ City Staff
Check(v)one
REFUND OR Name: V 0 1 I
INVOICE TO: (Business or Individual) S iAn.4y SeGm047 cOL (we s eigt5 O..
Mailing Address: 32510 ,s k A)k g go.
City/State/Zip: ivil Ls 0-4:4_ oft- °17267
Phone No.: 50.3 -Sin-;-163
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
FA CANCEL/VOID PERMIT APPLICATION,
►I 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#: E'LA 2.014— O p i3 9-
Site Addressor Parcel#: 1 .G Sf S Sw i4,4,a BOA, 124
Project Name: 1 O.FL(A,voS Pdt(L
Subdivision Name: r t crfroti. 11'P1 wt,. -t-P...44. Lot#: /3
EXPLANATION: r,4 5ra,�,t t r,,i N ce(,if A r h
Signature: _ Date: .2-2.3'L"
Print Name: Silty-cJ .CPIAL d._
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• Not more than 80%of the application or plan review fcc when an application is withdrawn or canceled before review effort
has been expended.
• Not mote than 80%of the application or permit fee for issued permits prior to any inspoctiQn requests. 02 D `7e+
2. All refunds will be returned to the original payer in the form of a check via US postal service. 0 e lri
3. Please allow 3-4 weeks for processing refund requests. .7S QO — 6 0 . o-v - /S, w
9.a-0 — 7 ao = - �
67, a0 /6 .epo
FOR OFFICE USE ONLY
Route to S.s Admin: Date . AVM O a Route to Records: Date ®r °,'tom S,
Refund Processed: Date MV/r B 01 Invoice Processed: Date B
Permit Canceled. Date ifd�E1LP" Parcel Tag Added: Date By
I:\Building\FormAltcVermitAc 0973 4.doc
q
TIGARD
City of Tigard
April 2, 2015
Stanley Security
Attn: Steven Snyder
3810 SE Naef Rd
Milwaukie, OR 97267
Re: Permit No. ELR2014-00237
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12085 SW Hall Blvd, #130
Project Name: Arellanos Sports Bar
Job No.:
Refund Method: ® Check#216965 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,
d
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: Stanley Security DATE: 3/26/2015
Attn: Steven Snyder
3810 SE Naef Rd REQUESTED BY: Dianna Howse
Milwaukie, OR 97267
TRANSACTION INFORMATION:
Receipt#: 198130 Case #: ELR2014-00237
Date: 10/23/2014 Address/Parcel: 12085 SW Hall Blvd,#130
Pay Method: CreditCard Project Name: Arellanos Sports Bar
EXPLANATION: Per applicant's request as customer 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
Permit Fee 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $6720
APPROVALS: SIGNA URES DATE:
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 ONIry
Case Refund Processed: I Date: `0-As By: I ,w
I:\Building\Refunds\RefundRequest.doc x 09/01/2010