Permit Support Document (160) City of Tigard • COMMUNITY DEVELOPMENT DEPARTM .N
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1 iti Request for Permit Action
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TIGARD 1 31 25 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or,gov
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TO: CITY OF TIGARD RECEIVED
Building Division O'f 1 9 2016
13125 SW Hall Blvd.,'Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingP
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FROM: fl Owner I i Applicant ,,,,, Contractor City Staff
Check(V)one
REFUND OR Name: wmemmam
INVOICE TO: (Business or Individual) j 0 ' - 0 , HY-)c.
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Mailing Address: 40.0 #CI StA3 (051-1---64-41F-E U\
City/State/Zip: [...a.10,_ 111111 1.4,).Q0 OR
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Phone No.: (I.S-65)1141 - 2 do-1-N
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (vr):
CANCEL/VOID PER [IT APPLICATION.
AA REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
H INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELc_2.0 I(0-00sqZ
Site Address or Parcel #: I 411 S.- SLA) . (Dia PkAA) 4)S0
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Project Name: 3cc2.33 ,m r
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Subdivision Name: Lot #:
EXPLANATION: fd-- 9 A cauil
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Signature: = . Date: 10 I q 116
Print Name: i .., t"
a - -,, LlUtne-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• Not more than 8tEl,of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80(1's of the application or permit fee fur issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a cheek via US postal service.
3. Please allow 3-4 weeks for processing refund requests. 9, ,,z f - ?LI. 4,2-, 7-- /f.6(-,
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date ft/4P 4., By
Refund Processed: Date7/N/Cr. 13' ' Invoice Processed: 1 Date By
.........
Permit Canceled: Dalt. t., ByParcel Tag Added: ' Date 13'
-1:\Building\Forms\RegPecrnitAction_A23(4.doe
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TIGARD
City of Tigard
November 14, 2016
Johansen Electric, Inc.
Attn: Charlynn Leifsen
16869 SW 65th Ave., #311
Lake Oswego, OR 97035
Re: Permit No. ELC2016-00578
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 4945 SW Sequoia Pkwy, #180
Project Name: Spec Space
Job No.: PCC233
Refund Method: /1 Check#222917 in the amount of$83.57.
❑ Credit card "return"receipt in the amount of$
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
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 KeguestforPermitAction 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: Johansen Electric,Inc. DATE: 11/7/2016
Attn: Charlynn Leifsen
16869 SW 65th Ave., #311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 405061 Case#: ELC2016-00578
Date: 7/20/2016 Address/Parcel: 4945 SW Sequoia Pkwy,#180
Pay Method: CreditCard Project Name: PCC233 Spec Space
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
��- ® a o r rh ` £ f e� . 9 E. i 1 ‘;'4 r I a "
e u �• � i ' ... .44441 Coaji-
Electrical permit220-0000-43103 $74.62
12%State Surcharge 100-0000-24001 8.95
TOTAL REFUND: $83.57
APPROVALS: SIG E /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
--; FQR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: ////,ef//4 By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010