Permit t
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City of Tigard •• coMMUNiTy DI�:A-I:I.OP,Ml NT DI:PMk 1J �,R'3 0 2016
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- Request for Permit Action eurioi >>GARD
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wxvw.tigard-or. i1
TO: CITY OF TIGARD
Building DivisionV it.
13125 SW Hall Blvd.,Tigard, OR 97223 /3i /k i fin,
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingermits@tigard-or.gov
FROM: n Owner Applicant , Contractor 0 City Staff
Check(✓)one
REFUND OR Name: k)
INVOICE TO: (Business or Individual) - TaZ9co/ �iKk.
Mailing Address: TO teit 4f?3'�C/
City/State/Zip: Cziaer-m-rws, e.. (1 7.01 1
Phone No.: (5 — ‘.3`0
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION. .07/19
t O
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� n� ON PERMIT (do not cancel permit).
Permit#: 1 2.5 // __• i a//q
Site Address or Parcel#: /014(6—. SIV iiigir,/ G/l 771‘.1,----1
Project Name: ,1 -Z.
Subdivision Name: Lot #:
EXPLANATION: /,‘ Al, lk , ,-
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Signature: ,
Date: 477,0•70/ 1
Print Name: ei___ `' 0
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• Not more than 800 of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 8000 of the application or permit fee for issued permits prior to any inspection revues s.
2. .All refunds will be returned to the original payer in the form of a check via L'S postal service. EA/D
3. Please allow 3-4 weeks for processing refund requests.
7c,2, 5-0 — $P, q /Y. -o
e,-70 - G . 94, ' /. 7V
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FOR OFFICE USE ONLY
Route to Sys Admin: Date 1 )/ ;y tel Route to Records: Date V 21' /J, By -��
Refund Processed: Date -/Ler By , Inv•ice Processed: Date By
Permit Canceled: Date //i(p ByJ1 Parcel Tag Added: Date By
I:ABuilding\Forms\RcyPermitAetiono1c
INI . tl
TIGARD
City of Tigard
April 28, 2016
Jack Howk Plumbing/Rescue Rooter
Attn: Joyce
PO Box 2830
Clackamas, OR 97015
Re: Permit No. PLM2016-00119
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10945 SW Mira Ct
Project Name: Lopez
Job No.: N/A
Refund Method: ® Check#220683 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 scope of work changed and permit was no
longer required. 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 1
TTY Relay: 503.684.2772 • www.tigard-or.gov
114
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: Jack Howk Plumbing/Rescue Rooter DATE: 3/31/2016
Attn: Joyce
PO Box 2830 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt#: 402383 Case#: PLM2016-00119
Date: 3/7/2016 Address/Parcel: 10945 SW Mira Ct
Pay Method: CreditCard Project Name: Lopez
EXPLANATION: Per applicant's request as scope of work changed and permit was no longer required.
Refund 80% of permit fees.
REFUND INFORMATION:' ','
Fee Description From Receipt Revenue Account No. Refund
Example:. Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit Fee 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 -tt,-e---
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: y/Zefr_k By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010