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Permit Support Document (16) 4,f tl 41'41,1:, II City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT I:8 1 3 (0• 1/ Request for Permit Action • vo , TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ' 'a-- TO: CITY OF TIGARD V 0 1 Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 3A07 ,S44/4- Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits@ngard-or.gov FROM: EI Owner El Applicant r4 Contractor El City Staff Check(V)one REFUND OR Name: INVOICE TO: (Business to Individual) Mailing Address: Pp la).EX City/State/Zip: br)001 Ok, C1101.1) Phone No.: 5D?) (o7 Sit I '55. PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (I): CANCEL/VOID PERMIT APPLICATION. 74 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). Permit #: Site Address or Parcel #: 0 LQ119 17, 11/-1 Of -Lila& Project Name: Subdivision Name: Lot#: EXPLANATION: JobWO a eon gliA Signature: „IN Alijim Date: , Print Name: &co, lit w k An. _ 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. ,feZ 9V, 9V 15* ,2 • 9-.2 37g3 FOR OFFICE USE ONLY Route to S s Admin: Date ,AArBriallIEMIPJ,,/ Route to Records: Date / '4&11IATIV Refund Processed: Date jte /7 Bydrily, Invoice Processed: Date By Permit Canceled: Date 3/(ey/7 By t9te,----Parcel Tag Added: Date By TABuilding\FormARNPermitAction_09i314.toc iliii, : . .4 . . TIGARD City of Tigard March 15,2017 Bear Electric Attn: Sarah Osterhoudt PO Box 389 Donald, OR 97020 Re: Permit No. ELC2017-00085 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10662 SW 127th Ct Project Name: Chaer Job No.: N/A Refund Method: ® Check#224067 in the amount of$50.33. ❑ Credit card"return"receipt in the amount of$ . 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, i4A I/ - , 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 T 1 GARD 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: Bear Electric DATE: 3/10/2017 Attn: Sarah Osterhoudt PO Box 389 REQUESTED BY: Dianna Howse Donald, OR 97020 TRANSACTION INFORMATION: Receipt#: 408721 Case#: ELC2017-00085 Date: 2/6/2017 Address/Parcel: 10662 SW 127th Ct Pay Method: CreditCard Project Name: Chaer EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees. S S § d ,7 a 1t d '` i F 1 • ti � '�� nrqo 14 9 g Electrical Permit 220-0000-43103 $44.94 12%State Surcharge 100-0000-24001 5.39 TOTAL REFUND: $50.33 APPROVALS: SIGN 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 FOR TIDEMARK;SYSTEM ADMINISTRATI©NUSE ONLY „ Case Refund Processed: Date: 3/2 7 By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010