Permit Support Document (156) AUG/02/2016/TUE 07,43 AM Rogers Electric FAX No, 4702354686 P. 002
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 'AUG
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1I.. Request for Permit Action Rot�II OF j
T i tU A r.,rl 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •rorww.tigar ,glifr "1111S70 '
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TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Pax: 503-598-1960 TigardBuil.dingPeriiits@tigard-or,gov `C
FROM: ❑ Owner Applicant ❑x Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: ' ° '- D Lin R. Rogers Electrical Contractors, Inc.
Mailing Address: 2050 Marconi Drive,Ste 200
City/State/Zip: Alpharetta, GA 30005
Phone No.: 770-772-7921
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED("):
co CANCEL/VOID PERMIT APPLICATION.
r 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#: ELC2016-00115
Site Address or Parcel#: 13939 SW Pacific Hwy.-Walgreens
Project Name: WG4-Weigreens
Subdivision Name: None Lot#: None
EXPLANATION: We were not awarded the work.We will not complete this work.
Signature: dpir- / Date: 8/1/2016 Print Name: L R. Rogers "
ftefnad Policy
1. The city's Community Development Director,Building Official of City Engineer may authorize the refund o£
• Any fee which was ettoneoualy 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 or ginal payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests. / S 7
-7s-09, 4 o ,a" /<5; a
FOR OFFICE USE ONLY
Route to Sys Adrnitt Date B. Route to Records; Date Aff/.. B' A►iAT
Refund Processed: Date Q '/ B 4.S4r Invoice Processed: Date By
Pettmit Canceled: Dau -4,//t, By ., r-' •arch,Tag Added: Date By
:\Building\Poems\RegPesrniuka23.
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111
TIGARD
City of Tigard
September 23, 2016
Lin R Rogers Electrical Contractors
2050 Marconi Dr., Ste. 200
Alpharetta, GA 30005
Re: Permit No. ELC2016-00115
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13939 SW Pacific Hwy
Project Name: Walgreens
Job No.: N/A
Refund Method: ® Check#222427 in the amount of$60.78.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$
Comment(s): Per applicant's request as job was completed by another contractor.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
fill it",
10-448".0-7-0, 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
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: Lin R Rogers Electrical Contractors DATE: 9/16/2016
2050 Marconi Dr, Ste 200
Alpharetta, GA 30005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 402040 Case#: ELC2016-00115
Date: 2/16/2016 Address/Parcel: 13939 SW Pacific Hwy
Pay Method: CreditCard Project Name: Walgreens
EXPLANATION: Per applicant's request as work was completed by another contractor. Refund 80%of
permit fees.
FUND INF r t E 4
Fge 8�1 � roi t a
t,!,.
tau. t r ple Perrrilt e .s 1 it :t!"1"&;
: 0 a a
Electrical permit 220-0000-43103 $54.27
12%State Surcharge 100-0000-24001 6.51
TOTAL REFUND: $60.78
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$50,000 Local Contract Review Board
0(, 1010I'`TyI1�12K SYSTEM AD l:NISTRAttPN U$riONL I
Case Refund Processed: n Date: /0/7/%6 By: e t'
I:\Building\Refunds\RefundRequest.doc x 09/01/2010