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Permit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RE liPill , CEIVED Request for Permit Action cC r ,;A�.1 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard- .�o2 6 2015 TO: CITY OF TIGARD eu°i�NG �V,SR� Building Division V , ,;1 13125 SW Hall Blvd.,Tigard,OR 97223 �!�!� Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits 0 td-or.gov FROM: ❑ Owner ❑ Applicant 2 Contractor ❑ City Staff (:heck(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) ER'��, F // 6 ( c Mailing Address: ('7 .. .FS 0 2 /g City/State/Zip: /../( ((j ‹j �� e-. -7 / 2 3 Phone No.: so 5 - - (� 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#: /L 2 °/ 5---- /O Site Address or Parcel#: f O 23s- ;:LA.. Ll'�� J 02c, iZ''Y Project Name: 61 j Subdivision Name: Lot#: EXPLANATION: >iL(64-g. -1-, ,zw �i zte , t T- 1:1074.2rf.Z._ cc ELC 45- 000 7 7 . Signature: (.i - Date: /2- /5 Print Name: j ,_ A 'Rail 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 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. S9,36 - 97. ` ' 7,' P7 7, is — .5-. _ = __Ay-2- •,g , /9 _/3 .. 7 FOR OFFICE I1SE ONLY Route to S s Admin: Date '� AMESI 'r:j' Route to Records: Date © B : Refund Processed: Date Ififigal B AlAy4 Invoice Processed: Date B Permit Canceled: Date LS B. ,y.:17' Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_6023 4.doc A TIGARD April 2, 2015 City of Tigard Ertell Electric LLC Attn: Dylan Wentworth PO Box 219 Hillsboro, OR 97123 Re: Permit No. ELC2015-00104 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10655 SW Greenburg Rd Project Name: I Fly Job No.: Refund Method: ® Check#216933 in the amount of$53.19. ❑ Credit card "return"receipt in the amount of$ . 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 this was a duplicate permit (see ELC2015- 00077). Refund 80%of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, 4 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: Ertell Electric LLC DATE: 3/26/2015 Attn: Dylan Wentworth PO Box 219 REQUESTED BY: Dianna Howse Hillsboro, OR 97123 TRANSACTION INFORMATION: Receipt#: 199453 Case #: ELC2015-00104 Date: 2/20/2015 Address/Parcel: 10655 SW Greenburg Rd Pay Method: CreditCard Project Name: I Fly EXPLANATION: Per applicant's request as this was a duplicate permit(see ELC2015-00077). 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 $47.49 12%o State Surcharge 100-0000-24001 5.70 TOTAL REFUND: $53.19 APPROVALS: SIGNATURES/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 ONLY��_ Case Refund Processed: Date: e//2/L5 By: `� 7V I:\Building\Refunds\RefundRequest.doc c 09/01/2011)