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REFUND REQUEST FORM
Permit No.: fl1 tZ` /0 0,2 Issued: d106-/oWl41"
Project Address: ‘04 1 SliI v!' 17 46)
Reason for Cancellation: C CU427
Refund Amount Requested: 'f ZP/
Requested by: Joyce Dennis, email: jdennis(Ci9ars.com
Thank you for your prompt response. Joyce Dennis,
CSR/Dispatch, 503-850-3100
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Certified Plumbing & Drain Specialists
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TIGARD
City of Tigard
June 3, 2016
Jack Howk/Rescue Rooter
Attn: Joyce Dennis
PO Box 2830
Clackamas, OR 97015
Re: Permit No. PLM2016-00182
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 6911 SW Cook St.
Project Name: Robinson
Job No.: N/A
Refund Method: ® Check#221213 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 the job was cancelled. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
464"77-i-t--
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
iil City of Tigard
T I G A RD 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/Rescue Rooter DATE: 5/26/2016
Attn: Joyce Dennis
PO Box 2830 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt#: 4030551 Case#: PLM2016-00182
Date: 4/5/2016 Address/Parcel: 6911 SW Cook St
Pay Method: CreditCard Project Name: Robinson
EXPLANATION: Per applicant's request as this job was cancelled. Refund 80%of permit fees.
1,14#1,0104A1.10 �_ o>u t:No r
ee I7escilptxnP`f4rom`Receip't /W40`4,-�,�� � � .�� ��
Example: B ailrting Permit Fee P pte,'2 e i t o t-43104 , y �:>!.
Plumbing Permit 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGN TURES 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 ON Y
Case Refund Processed: Date: 6 3 - B : ,ii.
I:\Building\Refunds\RefundRequest.doc x 09/01/2010