Permit Support Document (48) 04/07/2017 13:38 5036709572
IES COMMERCIAL INC `' JD 01/01
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City of Tigard • COMMUNITY DEVELOPMENT DEPAR71MEREI
quest for Permit Action
T I G A p.n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • � ® Q�/
TO: CITY OF TIGARz) BU `OF i��K, ►
li,L1xNG fl ��o�
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-19W Tigatd.Builclip.gPerm.its(n7tigard.-or,.gov
FROM: ❑ Owner
Check V)one ❑ Applicant. eContractor City Staff
FUND OR Name:
ITT• E TO: (Business or Individual) T6.5 coM 4.r C I P L C_.
Mailing Address: ( GIS 5- S c.J '-I '-$Th AU 6
City/State/Zip:
Phone No.: 3 - C,9 ( t7
P • E TAIL ACTION FOR THE ITEM(S) CHECKED (✓):
. CANCEL'/V s ID PERMIT APPLICATION.
REFUND P . IT FEES (attach copy of original receipt and provide explanation,below).
FOR FEES DUE (attach case fee schedule and provide explanation below).
Q REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: 61-C- 2-on — Cc'I g s`
Site Address or Parcel #: I (0 (Z.$ St4 12.0 b
• y.�4�7 t2 q1��N
Project Name: 6 tolovi
Subdivision,Name: C4 �2 t"ill). Lot#' . p
EXPLANATION: t Q.o 0- -- G t-tR,4t,.._ , ,
•
—fes t• may__Likat..t _ _j.._n 5 A. by A`t-. YvR-c. 2 Q t•wiz
y0� G r 4'04at
Signature:
Print Name:
rag: -�r. Date: y"7//
Refund 1 o 1
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• Not more than 80%of the application or plan review Ice when an application is withdrawn or canceled before review effort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 he returned to the original payer in the form of a check via US postal,service. r,vA fer,v
3. Please allow 3-4 weeks for processing refund requests.
96, , /4, 76 ,93 / y: 3
FOR OFFICE USE ()N1.4'
Route to S's fa min_ Date }/
Route Processed: Date �r ' Route to Records: Date ®6' ; ga m
Refund
Canceled: Date `im6J��!i!� 'InnO1Ce Ptocessed: Date
P�Permitn r t '41M-Parcel Tal Added: Date 01.111111111
h'1"Orms�ReriPcrmitAction_0 314.doc
TIGARD
City of Tigard
May 2,2017
IES Commercial Inc.
Attn: Corey Baysinger
16135 SW 74th Ave.
Tigard, OR 97224
Re: Permit No. ELC2017-00185
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 16125 SW 72nd Ave.
Project Name: Abbott
Job No.:
Refund Method: ® Check#224380 in the amount of$76.93.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
D Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as scope of work changed allowing use of minor
label and other permit ELC2017-00009 to complete the work. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
ttq
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
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 BequestforPermit 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: IES Commercial Inc. DATE:
Attn: Corey Baysinger 4/17/2017
16135 SW 74th Ave. REQUESTED BY:
Tigard, OR 97224 Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 409470 Case#:
Date: 3/16/2017 ELC2017-00185
Address/Parcel: 16125 SW 72nd Ave
Pay Method: CreditCard
Project Name: Abbott
EXPLANATION: Per applicant's request as scope of work changed allowing use of minor label and other
permit ELC2017 00009 to complete work. Refund 80%of permit fees.
n`.7S�hr );;;?:;*,,-JZ't zr 4 );;C
. --70.:
Electrical permit
12%State Surcharge 220-0000-43103 $68.69
100-0000-24001 8.24
TOTAL REFUND: $76.93
APPROVALS: SI U S/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
`` ?oR T ti RK ysTrAt ADM'INIS '!RA'TI(?N vsg,ONLY
Case Refund Processed: I �"
Date: I -� �3 /. B : t%ar .... ..a
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD
RECEIPT
ir
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: 79740
Site Address: 16125 SW 72ND AVE
Receipt Number: 415775 - 02/23/2018
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00185
$-76.93
Total: $-76.93
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Check CASHIER ID RECEIPT DATE RECEIPT AMT
224380
Payor: IES Commercial Inc. DHOWSE 02/23/2018 $-76.93
Total Payments: $-76.93
Balance Due: $76.93
Page 1 of 1
CITY OF TIGARD RECEIPT
II ■" `. 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
'k Ic;Ati3O
le--teff/t/4-(-----
1 Receipt Number: 409470 - 03/16/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00185 Branch Circuits wo/Purchase Service or 220-0000-43103 $85.86 e=
Feeder
ELC2017-00185 12%State Surcharge-Electrical 100-0000-24001 $10.30 ..f--
Total:
.f--Total: $96.16
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID USER108 RECEIPT03/16/2017 DATE RECEIPT AMT
Credit Card
Payor: Cathy Bell
087762
Total Payments: $96.16
$96.16
Balance Due: $0.00
•
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