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Permit Support Document (22) 1 TFP 0 RFCEIV V ..„,,,,,,, ixi___D JAN 24 201€ `i Vit' City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT II DING s lym X11 Request for Permit Action TIGARD 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 TigardBuildingPer€nits@tigard-or.gov FROM: ❑ Owner 14 Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Garri.br6..--/,er 'ri C. Mailing Address: 2,?20 SE 8, iiocc/Ave City/State/Zip: H-11/14_9, 6/2 g712-2 Phone No.: 663- 640 ZJ 4 C62 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). 0 REMOVE/REPLACE CONTRACTORV/2.016 ON PERMIT(do not cancel permit). Permit#: Ef/1/2.O/6 -005z 9 Site Address or Parcel#: /1342 t Fid (i 77OA/Ard()D f,/J. Project Name: M ITCH h WE Subdivision Name: ENLt✓ WOOD Na- 3 Lot#: ZZg -GGarner-El /�r EXI'I�ANA1'T V N: (��C r✓G��6 //Mt cl--'11-0-- C41,7�'cz.c - ©1,1 4-14 is primer/ Signature: Date: 1/ Z4/17 Print Name: eZ j 2, _ ( (' Refund Policy L 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. rad , — ��t 3 7 , eI, 59 /y. 76. -- /7,7,' _ ,2.93 .3 7. 7c,? / , / ' .:;L 7 ..5V FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Dat- /7 B Refund Processed: Date ,?/24///7 By 4 1r _, Invoice Processed: Date By Permit Canceled: Date o2/j/,7 By .00, arcel Tag Added: Date By I:\Building\Forms\Req permitAc tion_09231 .do c ,III a TIGARD City of Tigard February 9, 2017 Gamer Electric Atm: Melissa Stock 2920 SE Brookwood Ave Hillsboro, OR 97123 Re: Permit No. ELC2016-00529 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 11342 SW Cottonwood Ln Project Name: Howe Job No.: N/A Refund Method: ® Check#223735 in the amount of$110.18. ❑ Credit card"return"receipt in the amount of$ . 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 they did not complete the work on this project. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, 4 4P- 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 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 PermitAction 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: Garner Electric DATE: 2/2/2017 Attn: Melissa Stock 2920 SE Brookwood Ave REQUESTED BY: Dianna Howse Hillsboro, OR 97123 TRANSACTION INFORMATION: Receipt#: 404723 Case#: ELC2016-00529 Date: 6/28/2016 Address/Parcel: 11342 SW Cottonwood Ln Pay Method: CreditCard Project Name: Howe EXPLANATION: Per applicant's request as they did not complete the work on this project. Refund 80% of permit fees. r "e-D s w o ! `ot'` r'�' -0 2 . "fir # :�of ;l�X$tC.''A�,, _ -5e' 0 gt1E .,,m v^s".y.,r s. �' �r474-' ,it I N� rs' a''.30k11.1 1414.i,IfiliP 411: e c x`41. Electrical permit 220-0000-43103 $98.37 12% state surcharge 100-0000-24001 11.81 TOTAL REFUND: $110.18 APPROVALS: SIG TURES/DATE: If under$5,000 Professional Staff t _. 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 x ORTI A . SYTM MIISTATO �QL� ' # Case Refund Processed: Date: �/�y / 7 By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010