Permit RECEIVEP
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAR 3 2015
Request for Permit Action MY O ['GARD
Ti G A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.ti j4j ( �liV1SlON
TO: CITY OF TIGARD
v Building Division ,
13125 SW Hall Blvd.,Tigard,OR 97223 y 2//5 4//►
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigar -or,gov
FROM: ❑ Owner ❑ Applicant R Contractor ❑ City Staff
Chuck(✓)one
REFUND OR Name:
INVOICE TO: (Business of lndividunl) )1.-^-Q}-A-1 t s Lis C - )€ Q ,C i�_S
Mailing Address: - \� 15- 13 - \ / J� r)Q
City/State/Zip: \ e ' - \ , 0*--. t L ()DU J
Phone No.: s_1-50 - 5 - t...7-7 cl
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#: Ft._-_VV\ --2,--C.) 1- -' _OCYjcb
Site Address or Parcel#: \ ' 27 S u.. `i
Project Name: C'U 4--61,,N.
Subdivision Name: v• Y 2- Lot#:
EXPLANATION: /�-1-1/\,Z S In o'r 4 j j'- , c -rt-a--c�1
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Signature: \ _,J,.11q Date:
Print Name: ►i a. CØL .0,v--5CS
Refund Policy •
1. The ciry's Community Development Director,Building Official or City ling+inecr 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 foe 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, 7,2, so -- 5e. err
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FOR OFFICE USE ONLY
Route to S s Admin: Date —WLIIIIIMIMA Route to Records: ®� B 4,
Refund Processed: Date AZINIMIEMIVAM Invoice Processed: Dare B.
Permit Canceled: Date LIME B• •�rzr arcel T.-• Added: Date B
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TIGARD
City of Tigard
April 2,2015
Lewis Landscape Services
Attn: Marybeth Lewis
1915 NW Amberglen Pkwy, #400
Beaverton, OR 97006
Re: Permit No. PLM2015-00040
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 12337 SW Anton Dr
Project Name: Durham
Job No.:
Refund Method: ® Check#216949 in the amount of$64.96.
❑ Credit card"return" receipt in the amount of$ .
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 backflow device already existed. Refund 80%
of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
zi(&i (------.' , '.6`,''',/--(a...—
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: Lewis Landscape Services DATE: 3/26/2015
Attn: Marybeth Lewis
1915 NW Amberglen Pkwy, #400 REQUESTED BY: Dianna Howse
Beaverton, OR 97006
TRANSACTION INFORMATION:
Receipt#: 199321 Case #: PLM2015-00040
Date: 2/10/2015 Address/Parcel: 12337 SW Anton Dr.
Pay Method: CreditCard Project Name: Durham
EXPLANATION: Per applicant's request as backflow already existed. 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 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATUBFS/DATE:
If under$5,000 Professional Staff "-441.1 • 0J
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,O
Case Refund Processed: Date: /Z/,LS I By..��
I:\Building\Refunds\RefundRequest.doc x 09/01/2010