Permit Support Document (127) V 0 I 0
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
�� /� ^ /
1P11 �
al
= Re
Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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 ❑ Applicant ❑ Contractor ►a City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 0
'/ic1-L F-Lut.,s El PL-1.4,1M 6 ,tJ
Mailing Address: p Pao). j-7
City/State/Zip: `3eirt)ER_ C2EEK 012, Q7OO /
Phone No.: 503 CAS 7 — ?) cl i 9
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
• CANCEL/VOID PERMIT APPLICATION.
• REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
II INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: i L ti - CO q I '
Site Address or Parcel#: ( `5-- ..7 O c —7°1'14' (+U E-
-i2,Evvle--
Subdivision Name: Lot#:
EXPLANATION: ) ta.P Lip 11-1— E.. Pg21Lt rT — bt_u N Ele_ 71-L2€4)V
PLuLLtn Ds&,rt 1 rl e.E PLt-t p-o t(,—coo 3 9 •
Signature: ().CSk.,:. Date: %I?!1 to
Print Name: --I--. 4.,P)PDt Ptl,C-M 4,IAN 1
Refund Policy
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
''77�, JC7� ��//
/ �, - /Ye 5 o
p• 76 -- 4 , 7 _ % 7y
i 4 - . 94,
FOR OFFICE USE ONLY
Route to Sys Admin: Date 8 q 1 to B . ' Route to Records: Date//7 / :a/1
Refund Processed: Date j 4„pk, By •v Invoice Processed: Date By
Permit Canceled: Date
//�/"/f:e By ;/ice' Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_692314.doe
'►4 .
TIGARD
City of Tigard
September 23, 2016
Royal Flush Plumbing
PO Box 507
Beavercreek, OR 97004
Re: Permit No. PLM2016-00415
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15270 SW 79th Ave.
Project Name: Trevor
Job No.: N/A
Refund Method: Check#222450 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 this was a duplicate permit (see PLM2016-
00399). Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
1 11
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
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&quest 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: Royal Flush Plumbing DATE: 9/16/2016
PO Box 507
Beavercreek, OR 97004 REQUESTED BY: Dianna Howse
DA
TRANSACTION INFORMATION:
Receipt#: 405479 Case#: PLM2016-00415
Date: 8/9/2016 Address/Parcel: 15270 SW 79th Ave
Pay Method: CreditCard Project Name: Trevor
EXPLANATION: Per applicant's request as this was a duplicate permit;see PLM2016-00399. Refund
80%of permit fees.
,AtND
F INNORM*.a41O "Y rte'a aw l
'Fee Desc ii
pton"Fro m e` ipt fi � f enue '60**-ttitt v i a
l 6 3�d g l e mlt 1. . � � X00-43104 -aa . . dk
Plumbing Permit 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIG ES 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
s:FOKTIP:t- t1 T YStrAtADMOVISTRA'IION- TS,E m
Case Refund Processed: Date: /0//6 By: ocliet
a �gg
I:\Building\Refunds\RefundRequest.doc x 09/01/2010