Permit Support Document (41) City ofTigard • (;O\r?,lI_"NIIA DI_t ELOP\fE?_':T L),,P.ART_ll V",ECEIVED. 'N '
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Request for Permit Action JUN
TIGARD 13125 S\\ Hall Blvd. • Tigard, ()re ,na 9-223 • 503-7-18-2-139 . www.tiserty 6 2017
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TO: CITY OF TIGARD �I�+�Q
Building Division V
13123 Stiff''Hall Blvd.,Tigard, OR 97223 J 02://t
Phone: 303-718-2439 Fax: 503-598-1960 TigardBuildingPermits@cigar of g/ot-
FROM: Owner I I Applicant Contractor
check ✓,one Cit< Staff
REFUND OR Name: b4i
INVOICE TO: 'Business or Indi„ / gS du:11 a tXRcG 0 ��C jL/` L
Po Nath
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Address: .. a3� ';
City/State/Zip: 0.A-Cle4s, eg.6-pi /S
Phone No.: C71R- e6-C) 3i60
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): i2.40
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CANCEL/VOID PERMIT APPLICATION.
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REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n IN 'OICE FOR FEES DUE (attach case fee schedule and provide explanation below).
fl REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: P ”t 201 0/W
Site Address or Parcel #: ( I0 `5/ e (j g /16'f)
Project Name: i4/Z45St � al /
Subdivision Name: Lot#:
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EXPLANATIOw: D D /l/�t////li. /yam I,
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Signature: , ' i
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Print Name: /
Refund Policy
l. The city's Community Development Director,Budding Official or Cite Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80'0 of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80°o 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. 7
F, 70 4 1.(, _ /. 75%
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FOR OFFICE USE ONLY
Route to Sys Admin: Date sj :v A 1 Route to Records: Date •47
Refund Processed: Date . Bt .4f ���'� By h
7 Invoice Processed: Date By
Permit Canceled: Date_ ,:„)..//1- ByParcel Tag Added: Date By
L\Building\Forms\RegPermit\cuon_1 231(doe
IIII
TIGARD
July 26, 2017 City of Tigard
Rescue Rooter/Jack Howk Plumbing
Attn: Joyce Dennis
PO Box 2830
Clackamas, OR 97015
Re: Permit No. PLM2017-00179
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13215 SW Genesis Lp
Project Name: Riles
Job No.: N/A
Refund Method: ® Check#225432 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 they took the permit out for the incorrect scope
of work (corrected under permit PLM2017-00182). Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
�
�ta
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
c
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: Rescue Rooter/Jack Howk Plumbing DATE: 7/6/2017
Attn: Joyce Dennis
PO Box 2830 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt#: 410626 Case#: PLM2017-00179
Date: 5/16/2017 Address/Parcel: 13215 SW Genesis Lp
Pay Method: CreditCard Project Name: Riles
EXPLANATION: Per applicant's request as they took the permit out for incorrect scope of work
(corrected under PLM2017-00182). Refund 80%of permit fees.
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Plumbin. Permit 230-0000-43101 $58.00
12%State Surchar:e 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES DATE:
If under$5,000 Professional Staff49
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
Case Refund Processed: Date: A _y-. /de' By: veil'
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
U
f 8 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: RILES
Site Address: 13215 SW GENESIS LOOP
I Receipt Number: 415904 - 03/02/2018
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
PLM2017-00179
$-64.96
Total: $-64.96
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 225432 DHOWSE
Payor: Rescue Rooter/Jack Howk Plumbing 03/02/2018 $-64.96
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD RECEIPT
t a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: RILES
Site Address: 13215 SW GENESIS LOOP
I Receipt Number: 410626 - 05/16/2017
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
PLM2017-00179 Sink 230-0000-43101
PLM2017-00179 12%State Surchar e-Plumbin $$8.70
g 9 100-0000-24001 $8.70
PLM2017-00179 Minimum Fee Adjustment-Plumbing 230-0000-43101
$47.48
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 039465 PUBLICUSER109 05/16/2017
Payor: ARS PORTLAND PERMITS $81.20
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1