Permit To Page 2 of 2 2015-08-24 17:50:15(GMT) 15039721861 From: Charlynn Leifsen
V o I
City of Tigard • CO.MMUN ITV .DEVELOPMENT DEPARTMENT j
/6//i5
Request for Permit Action
TIC,A t:u 13125 SW Mall Blvd. • Tigard,Oregon 97223 . 503-718-2439 •w-w v.fi rrd-or.gov
TO: CITY OF TIGARD RECEIVED
Building Division
13125 SW Hall Blvd.,Tigard,OR 97?23 AUG 2 4 2015
• Phone: 503-718-2439. Fax: 503-598-1960 Ti gardIiuildingPcrinits@tigard-6. OF TIGARD
FROM: ❑ Owner pplicant ❑ Contractor ❑ City St WILDING DIVISION
(peel;(1)one
REFUND OR Name:
INVOICE TO: alusine"or lndO'idual) �•- e(h _.
Mailing Address: oC �, jl, 6.c4-1.
'.� Ave_
City/State/Gip: tt lft;'P! Ci Cl17/;) C-
Phone No.. t_ r }' t4 1 _ c ;
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). -
12] REMOVE/REPLACE CONTRACTOR.C.).N PERMIT (do not cancel permit).
Permit#: L�G20 0- C 7
Site Address or Parcel#: i (014 2' 7410
Project Name: VIAitkfli>r)
Subdivision Name: Lot#:
EXPLANATION: Nom ,
Signature:
Date://��'" ate: j
C
Print Name: _- x,11 ."..
A. _ l t
Refund Policy
I. 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• Not more than lIlY's of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than$If of the anplicatwn or permit tee forissued 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. oZ t g� — L�O ,, 3 - , y 6 O
/`/' 7(o — C
/ 709' - Q - ,S5
FOR OFFICE I`SE? ONE)
Route to S Admin: Dare Aimuzgumm Route to Records: I /S B 1
Refund Processed: Dare , / _ By J� Invoice Processed: Date j By
Permit-Canceled: Date /S i By �(!'•- 'arcel Tag Added: Date I Be _J
\Buildint\Forms\Rrv:insinitAcrxm Cr 2.14.tex
N
• .,.
TIGARD
City of Tigard
October 1, 2015
Johansen Electric Inc.
Atm: Charlynn Leifsen
16869 SW 65th Ave. #311
Lake Oswego, OR 97035
Re: Permit No. ELC2015-00406
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16420 SW 72nd Ave
Project Name: Miratron
Job No.: N/A
Refund Method: ® Check #218719 in the amount of$110.17.
❑ Credit card "return" receipt in the amount of$ .
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$ .
Comrnent(s): Per applicant's request. Refund 80% of permit fees. Note: The enclosed
check is in the amount of$160.50 for this permit and permit ELC2015-00509.
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
City of Tigard
TIGARD Accela Refund Request
ta
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: Johanson Electric Inc. DATE: 9/14/2015
Attn: Charlynn Leifsen
16869 SW 65th Ave. #311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 200953 Case#: ELC2015-00406
Date: 5/27/2015 Address/Parcel: 16420 SW 72nd Ave.
Pay Method: CreditCard Project Name: Miratron
EXPLANATION: Per applicant's request as customer cancelled job. 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 $98.36
12% State Surcharge 100-0000-24001 11.81
TOTAL REFUND: $110.17
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//// By: f
I:\Building\Refunds\RefundRequestdoc 09/01/2010
To Page 1 of 2 2015-08-24 17:50:15(GMT) 15039721861 From: Charlynn Leifsen
FAX COVER SHEET
TO
COMPANY
FAXNUMBER 15035981960
FROM Charlynn Leifsen
DATE 2015-08-24 17:49:25 GMT
RE permit refund
COVER MESSAGE
Charlynn Leifsen
*Secretary/Treasurer*
Johansen Electric, Inc.
P (503) 747-2503 I F(503) 972-1861
http://www.johansenelectric.com
WWW.METROFAX.COM