Permit Support Document „..,../(If,: /6 '4i....'f''''
RECE�V :r ;
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
74 NI .1
Request for Permit Action AuG 6 S 'n1F
T I G A R I7 13125 SW.Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •wtiv .iii a c,fir . cry'A i
TO: CITY OF TIGARD
Building Division ,I
13125 SW Hall Blvd.,Tigard,OR 97223 I
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: [I] Owner ❑ Applicant t Contractor ElCity Staff Y
Check(✓)one
REFUND OR Name: :,
INVOICE TO: (Business or Individual) /D T J J C. 9
Mailing Address: -7q q,9 S;l&) C t j r'u S c .
City/State/Zip: )9C%U-2,kir't-C-y1 6\cc(---/ oo '`i
Phone No.: �G j LtcpcT 1'2.4 ( !�
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
F. CANCEL/VOID PERMIT APPLICATION.
Z. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). .1
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
i
Permit#: ELR'2 j j (e ' 00053 f
Site Address or Parcel#: , I 44 5 Sln.J GtC k- ( C \�-i,V 'AO
Project Name: (” 1 c___Q ,r5 (\ (O, C7`/t'�
Subdivision Name: t 11)-\-e jr-Z?t' I.Ltite T CC16:-c- Lot#: 9
EXPLANATION: (I. 9 \- Y\jC'�t (� eCLMc.. LC c Y-`S 'CGt 1l 0
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Signature: "_ J„`'-",ll' "il)u,,�'�� � Date: S (S'( 1
Print Name: ,( cry^ , 011.cal� 'N(,t''
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. AU 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. `�
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FOR OFFICE USE ONLY ' .
Route to Sys Admin: Date By .%,/i , Route to Records: Date /19 7 /k, By !'lrf'
Refund Processed: Date /ei //6 By j,y ii. . voice Processed: Date By
Permit Canceled: Date 9' /p7/4., By . ...1"11. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_9231 .doc
'PI
TIGARD
City of Tigard
September 23,2016
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr.
Beaverton, OR 97008
Re: Permit No. ELR2016-00081
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11945 SW Pacific Hwy, #240
Project Name: Sriders India Imports
Job No.: N/A
Refund Method: ® Check#222392 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
Ill
. '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: ADT LLC DATE: 9/16/2016
Attn: Lori McMurphy
7989 SW Cirrus Dr REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 402914 Case#: ELR2016-00081
Date: 3/30/2016 Address/Parcel: 11945 SW Pacific Hwy,#240
Pay Method: CreditCard Project Name: Sriders India Imports
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees.
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Electrical
220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNAT .S/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
� f£k ' ` : MINIST1 ATIDN V O�L t h
Case Refund Processed: Date:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010