Permit Support Document (165) AUG. 29. 2016 10: 36AM 5032397038 Na 6842 P. 1/2
RECOVEti
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ZQ IU
• -':a Request for Permit Action NUG 2 _.4
TIGARD. 13125 SW Hall Blvd. • Tigard,Oregon 97223. 503-718-2439 • ar i 10 \ ' ) °`ti
•
TO: CITY OF TIGARD V 0 !
Building Division
13125 SW Hall Blvd_,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPennit rz Cigar' d-or:gov
FROM: ❑ Owner 0 Applicant ❑ Contractor ❑ City Staff
Check(1 one
REFUND OR Name:
INVOICE TO (Busioess ur Individual) American Heating
Mailing Address: 5035 SE 24th avve
City/State/Zip: Portland Oregon
Phone No.: 503 239 4600
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 permit).
Permit#: Et 2016-00196
Site Address or Parcel#_ 10200 SW Greenburg RD 200
Project Name: Farmers Insurance —
Subdivision Name: Lot#:
EXPLANATION: Pnuematic Building no need for low volt for HVAC
Signature: � _ Date: �'aq
Print Name: _Y--4,1 _0(s L) c-\ s47%--
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• Not more than 80%of the application or plan review fee when an applicadon is withdrawn or canceled before review effort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.
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FOR USE ONLY
Route to Sys Admin: Date B Route to Records: Dare in 7 /G By dre7
Refund Processed: Date MET. voice Procested: Date By _
Permit Canceled: Date Parcel Ta Added: Date B _
I:\13w1ding\Forma\Regpermiulcrio& 231 .doc
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.111
TIGARD
City of Tigard
September 23, 2016
American Heating
Attn: Brandon Hutchinson
5035 SE 24th Ave.
Portland, OR 97202
Re: Permit No. ELR2016-00196
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10200 SW Greenburg Rd., #200
Project Name: Farmers Insurance
Job No.: N/A
Refund Method: ® Check#222393 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 building has pneumatic controls and permit was
not required. 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
.1.114 ° 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: American Heating DATE: 9/16/2016
Attn: Brandon Hutchinson
5035 SE 24th Ave. REQUESTED BY: Dianna Howse
Portland, OR 97202
TRANSACTION INFORMATION:
Receipt#: 405515 Case#: ELR2016-00196
Date: 8/10/2016 Address/Parcel: 10200 SW Greenburg Rd,#200
Pay Method: CreditCard Project Name: Farmers Insurance
EXPLANATION: Per applicant's request as pneumatic controls;no need for permit;refund 80%of permit
fees.l
� UND;INj'ORMATr s iWtrt. r =W d a t •:
�D� ! %
`r ?�•,`Buil !itl ermit ee .,., V� *-� a n y 0:44i
i 10,A1,41-.$. � :4t a
. 4 .
Electrical permit 220-0000-43103 $60.00
12%State surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division ManagerIf
---
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
000 TIMMA SYs'I'FIWOM,r14isTitATTOX
Case Refund Processed: Date: I /0/7//k By: r v
I:\Building\Refunds\RefundRequest.doc x 09/01/2010