Inspections (3) 03/24/2016 09:36 American Contracting 5032449556 110. 179 #001
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City of Tigard . COMMUNITY DF.VRT.OPPtg( 6°1--
NMP,NT DEPART l r.NivED
,I g . Request for Permit Action MAR 2 4 2016
Tr i i i AR') 13125 SW I lall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ri;•a.- C.1t -0Q.:; •
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TO: CITY OF TIGARD
Building Division
13125.SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Har: 503-598-19G0 TigardBuildingPermits@tigard ur.gov
FROM: ❑ Owner n Applicant ,K Contractor fl City Staff
r}aa:Ik(V)one
REFUND OR Name:
INVOICE TO: (�usmess ur lnd0vidu;,l; .�ay lex Vv-u,e�,er /4vnei,cv't 1� '`61
Mailing Address: 7F6 6 S w OieSoyi ie
City/State/Gip: b YTUL V1 .. 1_. OK 417 )-2-3 ...
Phone No.: TDJ 1-407`FS- g
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1'):
(:ANCEL/VOID PP.RMIT APPLICATION.
RE1'lJN1) PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE, FC)1I 1:1d l S DUE (attach case fee schedule and provide explanation below).
❑ Rr MC.)V1/REPLACE.CONTRACTOR ON PERMIT(do not cancel pernnit).
Permit#: Mehr: 2D I (p C)017 g
Site Address or Parcel If: \-2-. 75 S t-ca I 114.1.' R.—
Project:
Project: Name: ,9-S—W>`0 I nS
Subdivision Name: I..ot#:
EXPLANATION: t {.S YY�I a' / A.t pe/ r / / • __al / d�
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Signature: , , a,-- - Date: 3 —2_5-- 1 tP
Print Name: 4,. IGI�L,ve c5*R r
Refund Policy ,J
1. The,-fry's Community Development Director,Building Official or City Engineer may authorize the refund of!
• Any fee which was erroneously paid or collcctcrl.
• Nut more than R()'%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Nut more than Rfl Y of the application or permit fee tur issued permits 17rinr to any inspection requests.
2. All refunds will he returned to the original payer in the Loan ci it ehcr.k vra I IS postal service.
4. Please allow 3-4 weeks for processing refund recitreats.
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FOR.^FFICE USE ONLY
Route to Sys Ailmin: Date,,ice / i rte. Route to Records: Date �%:I
Refund Processed: Date Y , APE ' ' Invoice Processed: Date _ By
Permit Canceled: Date 3�, / /fp j By ,,,f,r ,arccl Tag Added: Date by ..-
1:1iittilding\Fo rm:\RcyPcrmitAt noni10..31 .dor. ...
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TIGARD
City of Tigard
April 28, 2016
American Contracting
Attn: Kayla Krueger
7855 SW Oleson Rd
Portland, OR 97223
Re: Permit No. MEC2016-00178
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7500 SW Dartmouth St., #190
Project Name: Which Wich
Job No.: N/A
Refund Method: ® Check#220626 in the amount of$80.64.
❑ Credit card"return" receipt in the amount of$
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 customer cancelled job. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
42152R7,170.--pc___' _
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
'I 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 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: American Contracting DATE: 3/31/2016
Attn: Kayla Krueger
7855 SW Oleson Rd REQUESTED BY: Dianna Howse
Portland, OR 97223
TRANSACTION INFORMATION:
Receipt#: 402601 Case#: MEC2016-00178
Date: 3/17/2016 Address/Parcel: 7500 SW Dartmouth St,#190
Pay Method: Check Project Name: Which Wich
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.
Mechanical Permit Fee 230-0000-43102 $72.00
12%State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
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: r72.-1.-//(.0 By: --
I:\Building\Refunds\RefundRequest.doc 09/01/2010