Permit Support Document (51) From: 03/22/2017 10:07 11.420,P,001/004
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MA2017
Request for Permit Action
i A p,1) 13125 SW Hall Blvd. •Tigard,Oregon 97223. 503-718-2439 •www.tigard-or.gov # E
TO: CITY OF TIGARD V
0 1 .0
Building Division
13125 SW Hall Blvd.,Tigard,OR. 97223 `0
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Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingpermits®tigard-or.gov
FROM: 0 Ownerot
Check(I)one ❑ Applicant Contractor ❑ City Staff
REFUND OR Name: /�
INVOICE TO: (BusinessorIndividual) NW. MOWfl* J NJJ Ck�
Mailing Address: 144( SW b_50 , 4P�1
City/State/Zip: ti'1Cg OSUVW4D OI` 9103 C
Phone No.: " (017°
1411
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED(✓):
11 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).
REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: P011.-, 000W
Site Address or Parcel#: l �'?� SW V tcilaTD 4 J0'
Project Name: P1®PJ'r"( Amity r:424%/0.
1//� �� RA gi t/740
Subdivision Name: ",v 1 Lott'#•N'+
EXPLANATION:
Signature: Date:
Print Name: ll7( !� G[�
Refund Polity
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 an
2. All refunds will be returned to the original payer in the form of a check via USpostal service.
tspecuon requests. r'®
3. Please allow 34 weeks for processing refund requests. �" "'`�
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Route to Sys Admin: Date By Route to Records: Date tf /7 / B 4r-_w
Refund Processed: Date 7''/?,i7 - By t Invoice Processed: Date 7 y
Permit Canceled: Date y By
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TIGARD
May 2, 2017 City of Tigard
Bull Mountain Mechanical
Attn: Jack Hansen
16869 SW 65th Ave., #144
Lake Oswego, OR 97035
Re: Permit No. MEC2017-00055
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13773 SW Mistletoe Dr.
Project Name: Montgomery
Job No.:
Refund Method: ® Check#224336 in the amount of$80.64.
D Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as work was completed by another contractor.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
04
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
1111
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: Bull Mountain Mechanical DATE:
Attn: Jack Hansen 4/17/2017
16869 SW 65th Ave., #144 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 408472
Date: 1/24/2017 Case#: MEC2017-00055
Address/Parcel: 13773 SW Mistletoe Dr
Pay Method: CreditCard Project Name: Montgomery
EXPLANATION: Per applicant's request as work completed by another contractor. Refund 80%of
permit fees.
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Mechanical Permit .w _ ... � ,� sa" �I9 x .,y
12%State Surcharge 230-0000-43102 $72.00
100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGN D TE:
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
fV:i'- '.,*;0,,ti.i .A':,..
Case Refund Processed:
Date: 02 /efBy: i , ` ','-4.," � .�
I=\Building\Refunds\RefundRequest.doc x 09/01/2010
IN
CITY OF TIGARD
a 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
TIGARD
Project Name: Montgomery
Site Address: 13773 SW MISTLETOE DR
Receipt Number: 415777 - 02/23/2018
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
MEC2017-00055
$-80.64
Total: $-80.64
PAYMENT METHOD CHECK# CC AUTH.CODE
ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 224336
Payor: Bull Mountain Mechanical DHOWSE 02/23/2018 $-80.64
Total Payments: $-80.64
Balance Due: $80.64
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INCITii
Y OF TIGARD RECEIPT
' 13125 SW Hall Blvd.,Tigard OR 97223
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503.639.4171
TIt ARD
o&fEtWeeit
I Receipt Number: 408472 - 01/24/2017
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
MEC2017-00055 Furnaces>=100K BTU 230-0000-43102
MEC2017-00055 12%State Surcharge-Mechanical 100-0000-24001 $10.80
MEC2017-00055 $10.80
Minimum Fee Adjustment-Mechanical 230-0000-43102 $35.09
Total: $100.80
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 414230 PUBLICUSER136 01/24/2017
Payor: Laura Hansen $100.80
Total Payments: $100.80
Balance Due: $0.00
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