Permit Support Document May. 11. 2017 7: 36AM No. 4252 P. 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V I
/ .,
R Request uest Permit Action _572,/, 7 544/: ,
1 lc;A,it-b; 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • ww .ti r FIVE!).
TO: CITY OF TIGARD MAY 111 2017
Building Division Services Supervisor �,�T' ,' '�
1312$ SW Hall Blvd.,Tigard,OR 97223 B�1I� GAR;)
Phnite: 503.718.2430 Fax:' 503,598.1960 www.tigud-or.gov • INGDWISI
oN
FROM: 0 Owner • E App) pant . 1 Contractor . n City Staff
(check one)
REFUND OR Name; ADT LLC
It v Y OI4+-ri TO: (idutioetr-CA Individual) r n f
Mailing Addresb: 7989 SW Cirrus Dr
City/State/Zip: Beaverton,OR 97008
Phone No.: 503-469-7241
PLEASE •. ' ' \T1ON 'tilt THE " `n (S) KED (1);
0 CANCEL/VOID PERMIT APPLICATION.
P:1-1, REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
■ INVOICE FOR FEES DUE (attach ease fee schedule and provide explanation below),
• REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#t ELR2017-00099 .
Site Address or Parcel#: 12400SW Main St
Project Naive; Musis on Main
Subdivision Name: Lot##:
EXPLANATION; Fullpermit not needed-installint wireless s stems
Signature: „asis lite: 5/11/17
Lori McMurphy I;
Print Name; _ /5", ,-
aol c - /, fie,
I. r llire io:or 8uilaing Official nay authorize rhe refund of: G y �� �..74 /4; .� �
a) any fre which wait erroneously paid or collected, O
b) not more than 61O0/0 of the land use application fee when an appllearion it withdrawn or canceled before any.review effort has been expended.
e) nor mored aim 80%of the land use application fee for issued perm tc,• , •
el)"noc'more than 80%of the building plat,:e-re''fee wl.n an application it canceled before any plan review effort has been expended.
c) not more than 80%of the building permit fee for issued pen rata prior CO any inspection rrquesta.
2, Refundt will be returned to the original Payer in the same method in which payment wag received, Please allow 2-4 weeks for processing refunds.
Rte to S s Admin: Date 5// /7J B ,, / Rte to Bid/Admin: Date /f By %��=
Refund Processed: Dare ... 2 / B ,t/' Invoice Pxoee&sed: Date --ILPermit Canceled: _Dare . , / B *707 Parcel Ta; Added: Date By_
Recei r#t Date Method Amount$
1:\Building Forma\RegPereniulctiort.doc Rev 05%25/2012 �,--- -
a
TIGARD
City of Tigard
June 1,2017
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2017-00099
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12400 SW Main St.
Project Name: Musis on Main
Job No.: N/A
Refund Method: ® Check#224827 in the amount of$67.20.
❑ Credit card "return"receipt in the amount of$
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 permit was not required due to change in scope
of work. 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
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: ADT LLC DATE: 5/26/2017
Attn: Lori McMurphy
7989 SW Cirrus Dr REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 410474 Case#: ELR2017-00099
Date: 5/09/2017 Address/Parcel: 12400 SW Main St
Pay Method: CreditCard Project Name: Musis on Main
EXPLANATION: Per applicant's request as permit was not required due to change in scope of work
Refund 80%of permit fees.
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tre-
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Electrical Permit 220-0000-43103 $60.00
12%State Surchar.a 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGN U�ATE:
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
'h W'�s.+w?�%R* �g...✓ � .#ye�..� v+�,3�� l�I4I�Y,�,.��'*^.. +dr✓ �tilR �T� � £ JN�.�.�."`= Y*"�1 �`ro�:"�Y.ds".�YY#ar, '�14�:K{ a
Case Refund Processed: I Date: �702//c- By: I
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIG All
Project Name: Musis on Main 307917195
Site Address: 12400 SW MAIN ST /2 --cu�.6
IReceipt Number: 415894 - 03/02/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
$-67.20
ELR2017-00099
Total: $-67.20
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check
224827 DHOWSE 03/02/2018 $-67.20
Payor: ADT LLC Total Payments: $-67.20
Balance Due: $67.20
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III4
CITY OF TIGARD RECEIPT
g • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
,2/C/Aft/- -
Receipt Number: 410474 - 05/09/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2017-00099 Restricted Energy Permit 220-0000-43103 $75.00
ELR2017-00099 12%State Surcharge-Electrical 100-0000-24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 036764 PUBLICUSER107 05/09/2017 $84.00
Payor: Lori McMurphy
Total Payments: $84.00
Balance Due: $0.00
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