Permit Support Document (161) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IN
Request for Permit Action
T I G A R D 13125 SW I fall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
BuildingITY OF TIV I
13125 SW Hall Blvd.,Tigard, OR 97223 S'2-6// ; •t
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@ gard-or.gov
FROM: n Owner Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 6' ,V�e— E77 / e„diors eyh/6r7 A LL c
Mailing Address: 1/402 (/ 'L t 7 f9'"//e , /a) , S7 /06
City/State/Zip: /°4C,,944. U-/°, &J f}— 9t3 7/
Phone No.: .==.7...5'3 - e 7 a 6, O S /
I ,' C#9-7,44- V/6--72 -L
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
_/1E( CANCEL/VOID PERMIT APPLICATION.
iqr REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: L e Ae/6 -00 1//
•
Site Address or Parcel #: l..574) 6 .&2 /5V —
Subdivision Name: /0. ftyCp fM ff'.aif LL, /yam/re/AO Lot #: tP 0
EXPLANATION: C{/1i17 -67-1)2 /3 - tEA /°&7Zr,/7 O /14& /"I 677 'r-y,
Cf/JT7V9z rag-, r9-6 d /`1!7 O/S'-- (� /ca. • r iri✓%� /00'4
D, /0 72/-7 /7 , 5 , i
Signature: friC iIt I Date: ,5 Gl)
Print Name: 6 ,4v Ie . k_J
Refund Policy
I. The city's Community Development Director,Building()fficial or City I•:ngineer may authorize the refund of:
• .Any fee which was erroneously paid or collected.
• Not more than 80°=o of the application or plan review fee when an application is withdrawn or canceled beton'review effort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 pacer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 3 4., B ."
Refund Processed: Date �,/ By p nvoice Processed: Date By
Permit Canceled: Date -S✓/`� 4.. By ,A1-1!, Parcel Tag Added: Date By
I:ABuilding\Forms\ReyPennit-Action_t1 2314 oc
II
TIGARD
City of Tigard
June 3, 2016
Garner Electric Washington LLCq
Attn: Cara Vicarel
402 Valley Ave NW, Suite 106
Puyallup,WA 98371
Re: Permit No. ELC2016-00411
Dear Applicant:
1 The Cityof Tigard has canceled the above referenced permit(s) and encloses a refund for the
g p ( )
following:
Site Address: 15166 SW 154th Ave
Project Name: Polygon at Bull Mountain,Lot 60
Job No.: N/A
Refund Method: ® Check#221192 in the amount of$112.78.
❑ Credit card "return" receipt in the amount of$ .
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
E Trust account"deposit"receipt in the amount of$ .
Comment(s): Per applicant's request as contractor pulled permit online, but all work is
being performed under MST2015-00250. Refund 100% of perrmit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
I,
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: Garner Electric Washington LLC DATE: 5/26/2016
Attn: Cara Vicarel
402 Valley Ave NW,Suite 106 REQUESTED BY: Dianna Howse
Puyallup,WA 98371
TRANSACTION INFORMATION:
Receipt#: 403996 Case#: ELC2016-00411
Date: 5/19/2016 Address/Parcel: 15166 SW 154th Ave
Pay Method: CreditCard Project Name: Polygon at Bull Mountain,Lot
60
EXPLANATION: Per applicant's request as contractor pulled electrical permit online,but all work is being
performed under MST2015-00251. Refund 100%of permit fees.
REl'UND INFORMATION " ' _ } i,a
Pee'Z)gscriptio n From Receipt ReveiweTAct�oun 1 o . x 3•`
Example: $,uikding:Permit Fee Example: 2300Q00r43104 -' 0.1.;ehl'R
Electrical Permit 220-0000-43103 $100.70
12%State Surcharge 100-0000-24001 12.08
TOTAL REFUND: $112.78
APPROVALS: SIG URES/ ATE:
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
/,3//�o
Case Refund Processed: Date: ‘ By: 0���'
I:\Building\Refunds\RefundRequest.doc x 09/01/2010