Permit Support Document (163) . Apr. 29. 2016 1 : 02PM No. 3327 P.
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1
Request Permit Action qq/
Tlcj r D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.ti
TO: • CITY OF TIGARD • MAY 0 3 2016
Building Division Services Supervisor
13125 SW Hall Blvd. Tigard,OR 972233i a ads
Phone: 503.718.2430 Fax: 503.598.1960 www.dgard-or.gov '11
FROM: 0 Owner El Applicant u Contractor ❑ City Staff
(check one)
REFUND OR Name: ADT LLC
INVOICE TO: (Business or Individual)
•
Mailing Address: 7989 SW Cirrus DR
City/State/Zip: Beaverton, OR 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
// CANCEL/VOID PERMIT 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 permii).
Permit#: ELR2015-00223
Site Address or Parcel#: 9765 SW Frewing St
Project Name: Jeffera_&Julia Doan
Subdivision Name: North Tigardville Addition •• Lot#: 35
EXPLANATION: Customer cancelled install
Signature: `CLS �Q Date: 4/29/16
Lori McMurphy t1
Print Name:
7S,CrO — 6. 0 /s, or-a
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1, The Director or Building Official may authorize the refund of: .ero
a) any fee which was erroneously paid or collected. ---7-97C70 7.?-c)
b) not more than 50%n of the land use applicarion fee when en application is withdrawn or canceled before any review effort has been expended.
c) not more than,P0%of the land,use appJ cattion fee for isswed permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80°fin of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 6 b fly By 'V' Rte to Bldg Admin: Date 6 /4 By ,
Refund Processed: Date By Invoice Processed: _ Date By
Permit Canceled: Date 5/f By P.. ascel Tag Added: Date By
Receipt# Date Method ,— • Amount
l:\Building\Forms\RrgPermitA.cinn.doc Rev 05/25/2012
TIGARD
City of Tigard
June 3,2016
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2015-00223
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9765 SW Frewing St
Project Name: Doan
Job No.: N/A
Refund Method: ® Check#221179 in the amount of$67.20.
❑ Credit card"return"receipt in the amount of$
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,
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
1
III
i III
III 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 Reguest 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: ADT LLC DATE: 5/26/2016
Attn: Lon McMurphy
7989 SW Cirrus Dr REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 202713 Case#: ELR2015-00223
Date: 9/23/2015 Address/Parcel: 9765 SW Frewing St
Pay Method: CreditCard Project Name: Doan
EXPfLANATIp¢ON: Per applicant's request as customer cancelled job. Refund 80%of permit fees.
r ' x , ,h $ 1( yam!z; +" s ., ri ,w 7,
���•,$�e`ri���Buz Re���>{ :7:,,. .'.-::',:;'.-7. �' ` � �:�� `'�,�.�- '� �i°'4' i+ ' '� t$ � �F'�'''ti,
E#x nple`',3 dmg Permitt Fey �` cr" s$i i 0 43104 '��i:L t :'.
Restricted Energy Permit 220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGN D TE:
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: 4./3//cp By: ,c! ?) -
I:\Building\Refunds\RefundRequest.doc x 09/01/2010