Permit Support Document 09/02!2015 01:4f 5♦7dy`dki1bk7 L1 I Y LP I I( -Vii
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ,/einfr.
III I Request 13 for Permit Action
12 Mall Blvd.•Tigard,Oregon 97223 • 5O3 718 X439 •
TO CITY OF TIGARD Rtfp �' C ���'� fl!
Building Division l jl
13125 SW Mall Blvd.,Tigard,OR 97223 A
Phone: 503-718-2439 Fax 503-59S-1960 dingPacmits(r gard-or-gav •
FROM ❑ Owner D Applicant Conttactor ❑ City Staff
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REFUND OR Nave:
INVOICE TO ohaingt"ea Indlviduu() JEFFS N"ZC 4- ,Ca,1 .�.--
Mailing Address: .�
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Phone No.: 50-3 -201 aki
PLEASE TARE ACTION FOR THE ITEM(S)CHECKED(✓);
CANCEL/VOID PERMIT APPLICATION.
,tgai 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 pemrit).
Permit#: H (9-0
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Site Address or Parcel#: JILL
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Project.Name; TO/14 -314 040 Q[:GSr t C. 411-0
Subdivision Name: �p Lot#;
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1. The city's Community Development Director,Building Official or City Engineer may authcnit:c the refund of:
• Any[cc which wan erroneously paid or collected,
▪ Not mare than 80%of the appbmnon or plan review fen when no appEcatto11 is withdrawn or canceled before review effort
has been expended
▪ Not mote than 8O%of the application Of permit fee fen iaeucd pennies prior to any inspection requests-
2. At rcfun.ds will be+cwrocd to the ori&al payer in the form of a check via 1.13 pang Peruke.
3, Plow allow 3.4 conch for pmeceaing refund requesnt eFo 7-- /O i 70
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Route to S•s Admin: Date £74 WIIPE/•cote to Records: Date
Refund Processed: Date('AVM. B '/ Invoice Processed: Date B
PerenitCanceled: Date fzi / iS By •"' Patcal Tag Meted: Date -- By
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TIGARD
City of Tigard
October 1, 2015
Jeff's Heating& Cooling
Attn: Jeff Kubin
23875 Johnson Rd
West Linn, OR 97068
Re: Permit No. MEC2015-00505
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14115 SW Fern St
Project Name: Bahon
Job No.: N/A
Refund Method: ® Check#218717 & 218761 in the amount of$83.78.
❑ Credit card"return" receipt in the amount of$ .
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. Refund 80% of permit fees. Note: The enclosed
checks are for $74.80 refund of mechanical permit and$8.98 refund of 12% state surcharge.
If you have any questions please contact me at 503.718.2430.
Sincerely,
T1-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
1:111 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 farPermitAction 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: Jeffs Heating& Cooling DATE: 9/14/2015
Attn: Jeff Dubin
23875 Johnson Rd REQUESTED BY: Dianna Howse
West Linn, OR 97068
TRANSACTION INFORMATION:
Receipt#: 201818 Case#: NfC2015-00505
Date: 7/27/2015 Address/Parcel: 14115 SW Fern St
Pay Method: CreditCard Project Name: Bahon
EXPLANATION: Per applicant's request as as this was a duplicate permit(see MEC2015-00520). Refund
80%o of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Mechanical Permit Fee 230-0000-43102 $74.80
12%a State Surcharge 100-0000-24001 8.98
TOTAL REFUND: $83.78
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
s
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: I Date: I AO/V/-5— I By: •G
I:\Building\RefunJs\RefundRequest.doc x 09/01/2111)