Loading...
Permit Support Document (13) voiwp City- ©f Tigard cOlyIL NITY DE / � Request for Permit - ::TIGARD 0 I k '� 1312 SSC' I Jail Blvd. • Tigard, Oregon 922:q8l LI 31 f_{,-39 • \vct1 ti`ard-cir.go TO: CITY OF TIGARD _ 4 Aol--" Building Division :�k, �_,�-��� � 13 DIVI9111\ 13123 SAF'Mall Blvd.,Tigard, OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov FROM: I I Owner I I ApplicantContractor crock:(,/ on ( ( Gift Staff REFUND OR Name: /4'�'"'' �/ / �'C%u,��(� )��r` INVOICE TO: esu-in«s or Indoaduar. /( � C, L Mailing Address: Po An ne,WeVA'K City/State/Zip: CL "'akrAc, egq,'!/l S Phone No.: 1 Q9 PL ASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. a REFUND PERMIT FEES (attach copy of original receipt and provide explanation bel w). .32 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). I I REMOVE/REPLACE CONTRACTOR ON PERiMIT (do not cancel permit). Permit#: P✓ n/7D/ /ee ap.R1 Site Address or Parcel #: f Z4 5 S 130elegr 4j' Project Name: Subdivision Name: _ Lots EXPLANATION: ��** �t�- .i J 7 � � Signature: t.(/4"f Date: wog* Print Name: -N� Refund Policy I. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • Any fee which was erroneously paid of collected. • Not more than 80°'e of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80°-'0 of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original paver in the form of a check via US postal service. 3. Please allow 34 weeks for processing refund requests. 2,2, So ke s'te,cr-e /t4 Zit 4y 96 FOR OFFICE USE ONLY Route to Sys Admin: Dated 7 B ' Route to Records: Date y'21/ /7 By' '+- Refund Processed: Date /ey/T Bt•', Jam.v oice Processed: Date By Permit Canceled: Date c//7 By "' Parcel Tag Added: Date By I\Building\Porms';RcgPermitkction l 92314.doc 311 TIGARD City of Tigard March 15,2017 Jack Howk Plumbing Attn: Joyce Dennis PO Box 2830 Clackamas, OR 97015 Re: Permit No. PLM2016-00629 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 12405 SW Brookside Ave. Project Name: Hammond Job No.: N/A Refund Method: ® Check#224113 in the amount of$64.96. ❑ Credit card"return" receipt in the amount of$ 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 job was cancelled;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 1if 11 City of Tigard Accela Refund Request TIGARD This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request forPermit 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: Jack Howk Plumbing DATE: 3/10/2017 Attn: Joyce Dennis PO Box 2830 REQUESTED BY: Dianna Howse Clackamas, OR 97015 TRANSACTION INFORMATION: Receipt#: 408106 Case#: PLM2016-00629 Date: 12/27/2016 Address/Parcel: 12405 SW Brookside Ave Pay Method: CreditCard Project Name: Hammond EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees. kir y�r g �ranne r ° ro6 1tY rJ :, m{ p4'' Plumbing Permit 230-0000-43101 $58.00 12%State Surcharge 100-0000-24001 6.96 TOTAL REFUND: $64.96 APPROVALS: SIG TURES/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 ,FOII 11107E SySIVIADIVIINISTRATIONVSE:ON IX Case Refund Processed: I Date: I _3/71//7 By: l ' "— I:\Building\Refunds\RefundRequest.doc x 09/01/2010