ADJ2016-00007 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action V 0
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13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ',V-%vw.ti and-or ov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner a Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business orindividuan Leadership Circle LLC
Mailing Address PO Box 239
City/State/Zip: Montrose,CO 81402
Phone No.: 970-497-0066
PLEASE TAKE ACTION FOR THE ITEMS) 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 permit).
Permit#: ADJ2016-00007 (Related Case SDR2016-00004)
Site Address or Parcel #:13125 SW Pacific Hwy Project Name: Specialty Retail
EXPLANATION: Application amended avoiding the need for the adjustment
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Signature: � h Date: 3-24-2016
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Print Name: Gary Pagenst cher
Refund Policv
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 80%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.
3. Please allow 3-4 weeks for processing refund requests.
• ' OFFICE USE ONLY
Route to Sys Admin: Date Bv Route to Records: Date B
Refund Processed: Date / B Invoice Processed: Date By
Permit Canceled: Date . / B arcel Ta Added: Date B
I:\Building\Forms\RegPemutAction_ 923 4.doc
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City of Tigard
April 28, 2016
Leadership Circle LLC
PO BOX 239
Montrose,CO 81402
Re: Permit No. ADJ2016-00007
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13125 SW Pacific Hwy
Project Name: Specialty Retail
Job No.: N/A
Refund Method: ® Check#220659 in the amount of$769.00.
❑ Credit card"return" receipt in the amount of$
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): Application was amended avoiding the need for this adjustment. Refund
100% of the application fee collected under ADJ2016-00006.
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 0 www.tigard-or.gov
City of 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 PermitAction 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: Leadership Circle LLC DATE: 3/31/2016
PO Box 239
Montrose, CO 81402 REQUESTED BY: Dianna Howse
GP
TRANSACTION INFORMATION:
Receipt#: 402304 Case #: ADJ2016-00007
Date: 3/2/2016 Address/Parcel: 13125 SW Pacific Hwy
Pay Method: Check Project Name: Specialty Retail
EXPLANATION: Application was amended avoiding the need for this adjustment. Refund 100% of the
application fee of$769.00 which was collected under ADJ2016-00006.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Street Improvement Adjustment 100-0000-43116 $769.00
TOTAL REFUND: $769.00
APPROVALS: SIGNATURES/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: Z� / B
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
Gary Pagenstecher
From: Van Allen, Shivon <svanallen@dowl.com>
Sent: Tuesday, March 22, 2016 10:12 AM
To: Gary Pagenstecher
Subject: Tigard Natural Grocers Refund Request
Good morning Gary,
I'm requesting a refund ($769, 1 believe)for the adjustment that is no longer necessary for the Specialty Grocers
application.The refund issued will need to be made out to Leadership Circle, LLC, P.O. Box 239, Montrose, CO 81402
(the same account that issued the initial payment to the City). Please let me know what other information I can provide
for the refund request.
Thanks for your help with the project.
Best,
Shivon Van Allen
Planner
DOWL
INSPIRATION , INNOVATION . INTEGRITY
(971) 280-8641 (800)865-9847 (fax)
720 SW Washington Street, Suite 750
Portland, Oregon 97205
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