Permit 1 1
City of Tigard • COMMUNITY DEVELOPMENT DEPART9E L IVOID
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.1,111 = Request for Pernait A n ;; � / •
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T i;;1 R D 13125 SW Hall Blvd. -Tigard, Oregon 97223 • 503-718-2439 • w -
TO: CITY OF TIGARD !La/VG'U
Building Division ! i N 1 /670
13125 SW Hall Blvd.,Tigard,OR 97223 ' .
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Phone; 503-718-2439 Fax: 503-598-1960 TiiardBuildingPemits @tigaxd-or.gov
FROM: [] Owner ❑ Applicant 'retractor `1 V Cit)Staff.
Check(✓)one
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REFUND OR Name: 1 1
INVOICE TO: usineSS or Individual} / ` 4:-. - "r..) 41 A I .
Mailing Address; ,, 'S 0_ ,
City/State/;Gip: )0 •mi r. - r► . DI
Phone No.: raR"- 2-S'' 9.
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
• CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide ex0anation below).
• INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not/A-- -cancel permit).
Permit #: _ l.J 6 `- 1 .
Site Address or Parcel#: • ` A �` -
Project Name: 1 J te, ,, .
Subdivision Name:
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Lot#:I
EXPLANATION: 6. • g 1_a� • a.� .4 G•-
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Signature: IF ,
Date: -7/oh�: s-`
Print Name: R t
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may 2uthorize 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled befu a review effort
has been expended, Al
• Not more than 80%of the application or permit fee for issued permits prior to any inspection regiests./1 �,��j) g-67-it'
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. 11$ ,$V— 9,2 ;, y3 3
i / � — //� ag ;� .Z.72
/a5. Vo ,1 lo.,.S� a S��
FOR OTFIC_l; USE ONLY
Route to Sys Admin: Date 7®C5111 Route to Records: Date et, I/A111 ii
Refund Processed: INEWArirMIIIMMITLI Invoice Processed: Date
Permit Canceled: Date Vs S By . Parcel T.• Added: ! Date j HIE
I:\Building\Farms\RegPermitAcdon_(7923 4.doc i
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IN . n
TIGARD
City of Tigard
August 6, 2015
Squires Electric Inc.
Attn: Andres Cohen
657 SE Yamhill St.
Portland, OR 97214
Re: Permit No. ELC2015-00452
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10130 SW Nimbus, D5
Project Name: Nimbus Business Park D5
Job No.: N/A
Refund Method: ® Check#218221 in the amount of$103.52.
❑ Credit card"return" receipt in the amount of$ .
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.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/14- 6)----f-e---
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 fir 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: Squires Electric Inc. DATE: 8/3/2015
Attn: Andres Cohen
657 SE Yamhill St. REQUESTED BY: Dianna Howse
Portland, OR 97214
TRANSACTION INFORMATION:
Receipt#: 201214 Case #: ELC2015-00452
Date: 6/11/2015 Address/Parcel: 10130 SW Nimbus,D5
Pay Method: CreditCard Project Name: Nimbus Business Park D5
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%o of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $92.43
12% State Surcharge 100-0000-24001 11.09
TOTAL REFUND: $103.52
APPROVALS: SIGNAT :ES/DATE:
If under$5,000 Professional Staff/ G' -
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: 6P/6/8" Ify
By:
I:\Bull ding\Refunds\RefundRequest.doc s 00/01/20111
Cdtan
CITY OF TIGARD ELCTRIC'4L PERMIT
COMMUNITY DEVELOPMENT
Permit#: ELC2015-00452
Date Issuacl: 06/11/2015
T f t-_-;A RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439
Parcel: 1 S134AA01800
Jurisdiction: Tlgard,
Site address: 10130 SW NIMBUS AVE D5
Project: Nimbus Business Park unit D5 Subdivision: IKOLL BUSINESS CENTER,TIGARD Lot: 2
Project Description: Unit D5, Service and 2 circuits
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contractor: SQUIRES ELECTRIC Owner: HANSON, RONALD D
100 D ON "E' #1 ROBINSON, CONSTANCEA
P IRT,.' D, 0- • 02 ROBINSON, CHESTER TRUST ET AL
203604 EAST FINLEY S
lasM Parr• KENNEWICK,WA 9331
PHONE: 503-252-1609 PHONE:
FAX; 503-253-5831
FEES
Quantity Description 1 Date Amount
1 ea Services or Feeders-200 06/11/2015 $100.70
Specifics: amps or less
•
2 cri Branch Circuits w/Purchase 06/11/015 $14.84
Type of Use: COM Service or Feeder
Class of Work: ALT 1 ea 12%State Surcharge- 06/11/2015 $13.86
Electrical
Type of Conat:
•
Occupancy Grp:
•
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: Total 5129.40
Required Items and Reports(Conditions)
This permit Is Issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire If work is not started within 180 days of issuance, or if work Is suspended for more the 180
days. ATTENTION Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center, Those rules are set forth in OAR
952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344,
Issued By: Pennittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale.lease or rent.
OWNER'S SIGNATURE - , Date:
CONTRACTOR INSTALLATION ONLY
SIG)L?TURE OF SUPR.ELEC' Date:
LICENSE NO.
Cali 503.639.4176 by 7:00 a_m.for the next available inspection date.
This permit card shall be kept In a conspicuous place on the Job site until completion of the project
Approved plans are required on the Joh site At the time of each inspection.
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