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Permit 10/22/2015 10:59 5032665955 TRISTA PAGE 01/02 VOHJ ')1/// % l e f 9/s - l City of Tigard • COMMUNITY DEVELOP.MENI DEPARTMENT Ck + • = Request for Permit Action °°j2.2 V�!� �T .. S T I(;A N.[) 13125 SW Hall Blvd. • Tigard, Oregon 97223 - 503-718-2439 • _ww.t___ rin �� . ut.)/U/SAO TO: CITY OF TIGARD 40/V Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigaxd-or.gov FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff Check N')one REFUND OR Name: INVOICE TO: (liwine>5 Bt or Individual) t'E5 Lurn.I Mailing Address: 0 eJ City/State/Zip: _C DV l R 9.-9-0_, 3 Phone No.: U' — .(P(a — 5"9515---- PL ASE 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##: P I--(V\e�c O O 3 S 1 ' Site Address or Parcel#: _k "3`-‘ 5 5 W ft,5 h Folic) 51— T&ikci o Project Name: k— C{ k\ OD l'- -3, Subdivision Name: I l Pr- Lot#: 0 I A- EXPLANATION: 01)4 fqK k)(IT Dr "..) Signature: 41 Date: \O— a a 1 Print Name: ` iMr: ' - } Refund Itoliz 1. "Ihe city's Community Development Director,Building Official or City Engineer way authorise 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. Plirjsn allow 3-4 week,for processing refund reyueyts. -2,0,?, 50 ..‹/-1, /4/, Sc' �, 70 -- 4- .9¢ - /, 7V a - -�y, s4:, - lea y FOR OFFICE t'SlT ONLY Route to S•s Admin: Date -Mail! B, j] Route to Records: Date /9 © B Refund Processed: Date //MEM�B •'�A1 Invoice Processed: Date 13• Permit Canceled: Date .,i�®f MOM r- cel Ta Added: Date Be t:\luilding\norms\RcyPcrmieAcdon_09 314.d c j1 City of Tigard November 19, 2015 B. Ayres Plumbing Attn: Trista Ayres PO Box 149 Canby, OR 97013 Re: Permit No. PLM2015-00356 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 8425 SW Ashford St. Project Name: NK-Eklund Job No.: N/A Refund Method: ® Check#219183 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 job was cancelled. 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 • 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 RequestJr 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: B. Ayres Plumbing DATE: 11/06/2015 Attn: Trista Ayres PO Box 149 REQUESTED BY: Dianna Howse Canby, OR 97013 TRANSACTION INFORMATION: Receipt#: 400192 Case #: PLMLO15-00356 Date: 10/20/2013 Address/Parcel: 8423 SW Ashford St. Pay Method: CreditCard Project Name: NK-Eklund EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees. REF UN. I F ION:, Fee D - tgra; escri tion-From`Recei� f - - - - `Rev- ���"-�=�:�`-�-- P.y ;: eriieAccount'1Vo '�..-f�', Esample::::BuilduzgPerm>t Fee _Exai 1e:.2300000-4310-1_ ; $Amount-;: Plumbing Permit Fees 230-0000-43101 $58.00 12% State Surcharge 100-0000-24001 6.96 TOTAL REFUND: $64.96 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under $12,300 Division Manager If under$23,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION:USE Case Refund Processed: Date: r/`/0s By: ..c - L\Building\Refunds\RefundReyuest.doc x 09/01/2010