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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RE
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III f Request for Permit Action
13125 SW Hail Blvd. •Tigard,Oregon 97223 • 503-718,2439 • d-or
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TO: CITY OF T8vl��ll C til
Building Divisvisiloo n141:11)
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerntits@tigard-ot.gov
FROM: ❑ Owner Nts,Applicant tg Contractor El City Staff
Check(1)one
REFUND OR Name: '� 5
INVOICE TO: (Buslucea or Iadtvidua�
Mailing Address: -- : "i♦ at i,.S
City/State/Zip: 1:7MAZAild ,1
Phone No.: -17',--LQ -g 2 4
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
V'6__CANCEL/VOID PERMCT 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#: Li _.r I ' ~ _ t
Site Address or Parcel#: • 1NA 1 4P'
Protect Name: 66 et.— S
Subdivision Name: - Lot#:
EXPLANATION: J 0 Y I 0 J-A -Puy in- -I- 0 ., CW 1 ,
Signature: �] • Date: O� U2
Print Name:
1. ____W__11. J
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Refund Policy
1. 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• Not more than 80%of the application or plan review fee when an application Is withdrawn or canceled before review effort
has been expended.
• Not more than 804/t 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. , L�
3. Please allow 3-4 weeks for processing refund requests. d, ,,.�y __ 2.2,0-0 _ `ddCi
i-OR o:,FICE USE ONLY
Route to S s,Admin: Date , PINIIMPIP J Route to Records' Date 7/ - B 44...,
/ e • Invoice Processed: Date By
Refund Processed: Date ,� �y /__
Permit Canceled: Date ' .3/ //o . B r ► 'arcel Tag Added: Date By
I:\Building\Forms\RegPermitA.ction_0' 1 .doc
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TIGARD
City of Tigard
April 28, 2016
Fireside Distributors
Atm: Erin Pennington
18389 SW Boones Ferry Rd
Portland, OR 97224
Re: Permit No. MEC2016-00118
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10445 SW View Terrace
Project Name: Baltus
Job No.: N/A
Refund Method: ® Check#220652 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,
'S"5;)X4r7,4X-Pa
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
III 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: Fireside Distributors DATE: 3/31/2016
Atm: Erin Pennington
18389 SW Boones Ferry Rd REQUESTED BY: Dianna Howse
Portland, OR 97224
TRANSACTION INFORMATION:
Receipt#: 402137 Case#: MEC2016-00118
Date: 2/22/2016 Address/Parcel: 10445 SW View Terrace
Pay Method: CreditCard Project Name: Baltus
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: SIGNAT _RES/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: '//2d��/c„ By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010