The URL can be used to link to this page

Permit Support Document (168) Ir.. V 0 I F City of Tigard 0 COMMUNITY DEVELOPMENT DEPARTMENT. . n _ A,/ /c) .Vk---- , 4 . , i 2 Request for Per .t Action II A_ A ' E(*(711 ED TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • \\--ww.trvyard:orrov. nIQ / R u,6 TO: CITY OF TIGARD on:OF TIGARD Building Division 81111NG P,IPIS ION 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 Tigardl3uildingPermits@tigard-or.gov FROM: Li Owner Applicant 2 Contractor E. City Staff check(v)oar REFUND OR Name: 'Triton Communications,LLC INVOICE TO: (Bu$iness'-'1"individual) Mailing Address: 8215 SW Cirrus Drive City/State/Zip: Beaverton, OR 97008 Phone No.: 503-615-5800 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): K. CANCEL/VOID PERMIT APPLICATION. U REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below) 1— REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: ELR2016-00248 Site Address or Parcel #: 13560 SW Pacific Hwy Project Name: Starbucks Subdivision Name: Lot#: EXPLANATION: Permit not needed. Minor label permit was used on job. Signature: "1.111,1 ''''\--,-----A --- ' A \ ...- Date: 11/9/16 ii. . , Print Name: in .-1W n f eet Refund Policy I. The city's Community Development Director,Building Official or City Ilmginecr may authorize the refund of: ® Any fee which was erroneously paid or collected. to Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. O 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 set-vice. 3. Please allow 3-4 weeks for processing refund requests. 9-C:cre — 6 41 .Cr-6 7- 4521 — / — j_j_aa12.. ' . FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date ,ffArAIIIIIWMZ-r4r Refund Processed: Date,/,2,,,y/,‘ By 4/ Invoice Processed: Date By _ Permit Canceled: Date - ; / By 4.1""' ' Parcel Tag_Added: Date B t:\Riaidtag\forms\ReqPermitAction_C) 14. ir IIIu, p TIGARD December 15,2016 City of Tigard Triton Communications LLC Attn: Julie Van Fleet 8215 SW Cirrus Dr. Beaverton, OR 97008 Re: Permit No. ELR2016-00248 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 13560 SW Pacific Hwy Project Name: HME Starbucks Tigard Job No.: N/A Refund Method: ® Check#223303 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 0 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 a minor label was used. Refund 80%of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, r C(217e 71-e___— Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171TTY 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: Triton Communications LLC DATE: 12/12/2016 Attn: Julie Van Fleet 8215 SW Cirrus Dr. REQUESTED BY: Dianna Howse Beaverton, OR 97008 TRANSACTION INFORMATION: Receipt#: 407126 Case#: ELR2016-00248 Date: 10/29/2016 Address/Parcel: 13560 SW Pacific Hwy Pay Method: CreditCard Project Name: HME Starbucks Tigard EXPLANATION: Per applicant's request as minor label was used. Refund 80%of permit fees. of xa pl • l ling Permit i' .'I a04 . •„ tee , .:.� ��Ir� ��4 " s d�� 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 Manager If under$25,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMAl1rIC;SYST"EM:AD INIS 'RATION-LYSE Case Refund Processed: I Date: 16//2 I By: t \Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT $; 13125 SW Hall Blvd.,Tigard OR 97223 �^ 503.639.4171 TIGARD X uALL , Receipt Number: 408246 - 01/06/2017 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELR2016-00248 �2 f /�j/7— 02 C C' "0a20 — y2/°—' �)$-67.20 " Q G /40-47O — 400a0 —..24100/—..24100/4/®O/ ? �02 � �� Total: $-67.20 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 223303 DHOWSE 01/06/2017 $-67.20 Payor: Triton Communications, LLC Total Payments: $-67.20 Balance Due: $67.20 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 111 _ 503.639.4171 TIGARD Receipt Number: 407126 - 10/29/2016 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELR2016-00248 Restricted Energy Permit 220-0000-43103 $75.00 ELR2016-00248 12%State Surcharge-Electrical 100-0000-24001 $9.00 Total: $84.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 08947G PUBLICUSER108 10/29/2016 $84.00 Payor: Melissa Breland Total Payments: $84.00 Balance Due: $0.00 Page 1 of 1