Permit RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 14 2015
11111 l;1TY(!F 1'I(;AkU
_ Request for Permit Action 11IL VOf DIVISION
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tlgara-or.gov
TO: CITY OF TIGARD
V 1
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 6 e ,$ 44
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ' Contractor ❑ City Staff
Check(l)one
REFUND OR Name: aw‘,... ei.,.,cA,e,,,t,
INVOICE TO: (Business or individual)
Mailing Address: i \ 5w CI)\u \ ho, tfj,(j(t
City/State/Zip: W 1 M l a.._ 617 020 1
Phone No.: M?) -- LA O' - `?34
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
ri 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#: oZQ/s-Vol o7 s
Site Address or Parcel#: 13$a,U u OT h ?y,NAji 5 l7
Project Name: ' O QAK:3 /672. Set 2
Subdivision Name: Lot#:
EXPLANATION: b , ' c-' - /�L.C',,2a/S_.-io3s
1 -
Signature: II.L. 'l' 'a,....--- Date: 5/43.-
Print Name: -' _1.1lb.
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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colt OFFICE LSE ONLY
Route to Sys Admin: Date By Route to Records: Date(; If S By 1 -
Refund Processed: Date i,7/5 By .j. , • uicc Processed: Date By
Permit Canceled: Date.//r/A B if' Parcel Tag Added: Date _ By
1:\Budding\Forms\ResPermitAction_09231 .doc
,' "
TIGARD
City of Tigard
June 18, 2015
Christenson Electric
Attn: Suzi Flowers
111 SW Columbia, Ste 480
Portland, OR 97201
Re: Permit No. ELR2015-00125
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13190 SW 68th Pkwy
Project Name: Infocus
Job No.: N/A
Refund Method: ® Check#217585 in the amount of$67.20.
n Credit card "return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
n Trust account "deposit" receipt in the amount of$
Comment(s): Per applicant's request as this was a duplicate permit (see ELC2015-
00356). 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
PrCity of Tigard
TIGARD Accela Refund Request
CD
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the ReqEestjbr 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: Christenson Electric DATE: 6/4/2015
Attn: Suzi Flowers
111 SW Columbia, Ste 480 REQUESTED BY: Dianna Howse
• Portland, OR 97201
TRANSACTION INFORMATION:
Receipt#: 200657 Case#: ELR2015-00125
Date: 5/8/2015 Address/Parcel: 13190 SW 68th Pkwy
Pay Method: CreditCard Project Name: Infocus
EXPLANATION: Per applicant's request as permit was a duplicate(see ELC2015-00356). Refund 80%of
permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit Fee 220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGN. - 'ES/DATE:
If under$5,000 Professional Staff 1., 47
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 ON Y
Case Refund Processed: I Date: I OA„IpS I By:
1:\Building\Refunds\RefundRequest.doc x 09/01/2010