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Permit Support Document (36) V 0 1 0RECEIVED -2/6//7 JUN 2 2 2017 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT III el CITY OF 1 iGARO Request for Permit Action BUILDING DIVISION TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223.503-718-2439•www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant [ Contractor 0 City Staff Check(✓)one REFUND OR Name: INVOICE TO: (B,uinessorindividual) LL►1 1Z 1Zoaer p FAT rr,Ya{ ('ns'V4-Ynr.#r ii 1r7C Mailing Address: 20 5o Alarcon i De- City/State/Zip: A\ 1n a f P�'�'f'1 /C,t't /:3000,5- Phone 3CQO.iPhone No.: -110 - 7 - 3'I 9 2- PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1): 21 CANCEL/VOID PERMIT APPLICATION. ® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). O INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below). O REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). Permit#: IC 2011- -ao 2.b0 Site Address or Parcel#: l 2{� �1 J 7_n[� kV F. Project Name: 7 1 Ow iS TY\ ail1r 0 an(I Poli- re ft Subdivision Name: !Pr Lot#: N 1k EXPLANATION: ProoCc t WAS catilc& d hes or e 4w k. was it Signature: uvia(4141 Date: tv jao I i Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 6, 6,7v --- 5 3 y %_. 6,i.. ?-- _ 5`O .13 FOR OFFICE USE ONLY Route to Sys Admix: Date By Route to Records: Date .g Z • B �%/�' Refund Processed: Date 7�' �r�0'' By 44". 6.voice Processed: Date By Permit Canceled: Date //4./f//7 s ' Parcel Tag Added: Date By I:\Buildiag\Fonns\RegPe®itAmon 0414.doc q TIGARD City of Tigard July 26, 2017 Lin R Rogers Electrical Contractors Attn: Paul Howell 2050 Marconi Dr. Alpharetta, GA 30005 Re: Permit No. ELC2017-00260 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 12615 SW 72nd Ave. Project Name: Lowe's Job No.: N/A Refund Method: ® Check#225410 in the amount of$50.33. 0 Credit card "return"receipt in the amount of$ 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 the job was cancelled. 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 0 MI - n 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: Lin R Rogers Electrical Contractors DATE: 7/6/2017 Attn: Paul Howell 2050 Marconi Dr. REQUESTED BY: Dianna Howse Alpharetta, GA 30005 TRANSACTION INFORMATION: Receipt#: 410061 Case#: ELC2017-00260 Date: 4/18/2017 Address/Parcel: 12615 SW 72nd Ave. Pay Method: CreditCard Project Name: Lowe's EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees. w7 6 r,. t-� 'md 3Y'"'7 ��'+�`. ? ,��.yi��1'�,Y '&,S � .�e+Y' 4 t*ni`P�''z"'✓d fi`�� A xf } � � �'_ ^?t `� �` Y�iY�t)1e� E �1 d4X4 xE LL;;fid .x Z� � ,#» � ,¢'Yi _ 1 �� w }t f E 8 IFIit tC y'Pr �� aY et .� ''a - na a E �R�'�s m�®.�.��a°!�°°axe � � d srXx. ash.' � E .; _ k" r ;•,z _Y, ..,.,, ru a.w. ,s.YS , ,'" ., s V�e$44.",t 4 Electrical Permit 220 0000-43103 $4.4,94 12%State Surchar•e 100-0000-24001 5.39 TOTAL REFUND: $50.33 APPROVALS: SIGNATURES 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 Case Refund Processed: Date: I i 02 �. , tl y; �� G B / I\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 111111 u* 13125 SW HaII Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: 2017 Lowe's Mailbox and Post Reset Site Address: 12615 SW 72ND AVE Receipt Number: 415910 - 03/02/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2017-00260 $-50.33 Total: $-50.33 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 225410 DHOWSE 03/02/2018 $-50.33 Payor: Lin R Rogers Electrical Contractors Total Payments: $-50.33 Balance Due: $50.33 Page 1 of 1 lig II CITY OF TIGARD RECEIPT g 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD &LIG(A/fl-L-- I Receipt Number: 410061 - 04/18/2017 I CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ELC2017-00260 Branch Circuits wo/Purchase Service or 220-0000-43103 Feeder $56.18 ELC2017-00260 12%State Surcharge-Electrical 100-0000-24001 $6.74 Total: $62.92 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID ER ID RECEIPT DATE RECEIPT AMT Credit Card 018163 CASHIER CASHIPUBLIUSER108 04/18/2017 Payor: Jamal Chehimi $62.92 Total Payments: $62.92 Balance Due: $0.00 Page 1 of 1