SUB2015-00010 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IN •
Request for Permit Action
T I G A R I) 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: E Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
4/0 CANCEL/VOID PERMIT APPLICATION.
(2(
'._- _ • i r- ' FEES (attach copy of original receipt and provide explanation below).
1,0) , ' ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
�, 111REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
,oft., Permit #: t 2-01S- — 000 / 40
401)
(.% Site Address or Parcel #: /2 000 r/ iv' 2 f v,-- i
�� s C
—412 , 6,72
'4/ 4 9.2- 44
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Subdivision Name: g— 'Irk S II"—II"— Pi/V 1?)>,6 E Lot #:
EXPLANATION: 1/9 2.c.9 4 t:4-t. <I-/v u 4/' i-s (pT(4)>)2 E 45
j--ger '` 5,-0-0L-•1..7> 73e ",-tP./iv- r S —7?‘.0 "///✓E- hi/se e c-c.1-•vOci s r/
C 1.4, #N c— c—fI .
Signature: <VC eC �� Date: Z P" /
Print Name: "4L.3eaZs----,5i 7.,t 1.. S
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date 9 /04., By
Refund Processed: Date A✓ — By Invoice Processed: Date By
Permit Canceled: Date /V/AL' By Parcel Tag Added: Date By
1:A Building\Forms\RegPermitAction_0923I 4.doc
n CITY OF TIGARD FEE AND PAYMENT HISTORY
i s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
SUB2015-00010 - 12000 SW VIEWCREST CT, TIGARD, OR 97224
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt# Due
Prelim Plat w/o PD 100-0000-43116 $6,117.00 $6,117.00 $6,117.00 5/28/15 Check 200998 $0.00
Prelim Plat w/o PD-LRP 100-0000-43117 $807.00 $807.00 $807.00 5/28/15 Check 200998 $0.00
COT Address Fee --m7 /14/LI'16- fir- 100-0000-43113 $192.04 $192.04 $192.04 12/10/15 Credit Card 400999 $0.00
Address Fee 100-0000-43113 $300.00 $300.00 $300.00
Totals for Fees $7,416.04 $7,416.04 $7,116.04 $300.00
Receipt# Payment Method Check# Payor: Receipt Date Receipt Amount
200998 Check 3854 Westwood Homes 05/28/2015 $6,924.00
400999 Credit Card william a wagoner 12/10/2015 $192.04
Total Payments: $7,116.04
Balance Due: $300.00
CITY OF TIGARD RECEIPT
1111 '1
13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
fV )
Receipt Number: 400999 - 12/10/2015
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SUB2015-00010 Postage(Land Use Applications) 100-0000-45319 $192.04
Total: $192.04
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 656438 PUBLICUSERO 12/10/2015 $192.04
Payor: william a wagoner
Total Payments: $192.04
Balance Due: $300.00
Page 1 of 1
CITY OF TIGARD RECEIPT
11111 .I
s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
/2-iCini191--
Receipt Number: 400999 - 12/10/2015
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SUB2015-00010 COT Address Fee 100-0000-43113 $192.04
Total: $192.04
PAYMENT METHOD CHECK# CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 656438 PUBLICUSERO 12/10/2015 $192.04
Payor: william a wagoner
Total Payments: $192.04
Balance Due: $300.00
Page 1 of 1