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Permit Support Document (50) VOL . 9 /y /2 tr-- City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMEN 01 3 Request for PermitE ,. q Acton 'Ef T i t_;Aim 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.ti and-ort g ,7- 4 i 2017 TO: CITY OF TIGARD AP 'GA RD Building Division G 13125 SW Hall Blvd.,Tigard,OR 97223 ISION l Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner j7,1 Applicant ❑ Contractor ❑ City Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) --3— N\ Secv \'' C Mailing Address: 15C.01-1 jjr Pe , 01 City/State/Zip: A m hO / , A ? O 1 Phone No.: j- a7%'33- 566 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANCEL/VOID PERMIT APPLICATION. IN_ 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#: /1 L r QC/ 7 --( 6Of Site Address or Parcel#: 1 L/ 1 7 3 .s‘,\J 15 5 1T Project Name: -Bf-i- 1 R f,e A Subdivision Name: Lot#: EXPLANATION: C'S -c wt er Can cel ea Jo h Signature: L,00e,e — — Date: 4'-/// 7 Print Name: Reb-e('C 0, Lams--c 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. G / ,°'0-17 -- 7a , CV /fiG?t„) . f .a_._.:1_' ) ..._.1. /• ry % „./6, /o-e) r-e) to, 6I/ ./ FOR OFFICE USE ONLY Route to Sys Admin: Date r( 11 i B, 3PPRoute to Records: DateS /,f fir By Refund Processed: Date //y/7 By .f f,7 Invoice Processed: Date By Permit Canceled: Date V/y/j 7 By mss,' Parcel Tag Added: Date By rm I:\Building\Fos\RegPermitAction_ 9231 .doc %I . q TIGARD September 21, 2017 City of Tigard J&M Contractor Services Attn: Rebecca Langston 15604 NE Reid Rd Amboy,WA 98601. Re: Permit No. MEC2017-00608 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 14173 SW 155th Ter Project Name: Reed Job No.: N/A Refund Method: ® Check#226159 in the amount of$80.64. ❑ Credit card "return"receipt in the amount of$ . 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 job was cancelled. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, ,62,-*57-446-471....-f—. 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 11111 p City of Tigard TICARD 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: J&M Contractor Services DATE: 9/14/2017 Attn: Rebecca Langston 15604 NE Reid Rd REQUESTED BY: Dianna Howse Amboy,WA 98601 TRANSACTION INFORMATION: Receipt#: 412304 Case#: MEC2017-00608 Date: 8/11/2017 Address/Parcel: 14173 SW 155th TER Pay Method: CreditCard Project Name: Reed EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees. 47":;-:":. 1:::`::.:-4-7'i.R $'�' °''f saes -� s��'k a^- ''':::5'''': . SAYS f' '4, 'i .rx f f'�2 —7 a# 7: '7 �.1";. -;, ' p5 ��, P,; w , xf , r� fi 4,'q r4,.F #` :, fi b es�yMN.,.,� 3srt mrs +:+<€r 7�cS�,��_.iqt:'��.��'��i.ro:�.f�3iia.�+.�.at_a.,t a.. „a:''''t-'1.1'W Y �`:Y� of Mechanical Permit �`� ° � ��`� �= .a�_ -0�.u� . �`��a a 230-0000-43102 $72.00 12%State Surchar. - 100-0000-24001 8.64 TOTAL REFUND: $80.64 APPROVALS: SI ' S/DATE: If under$5,000 Professional Staff '_' i , 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 a 0 s tf. .R1 !F est A 70.A."o , ""` Case Refund Processed: Date: "` .�,23 ./� . I By: I 41.4°' I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT g 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Brain Reed Site Address: 14173 SW 155TH TER ETzr/V_? Receipt Number: 416300 - 03/23/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2017-00608 $-80.64 Total: $-80.64 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 226159 DHOWSE 03/23/2018 $-80.64 Payor: J&M Contractor Services Total Payments: $-80.64 Balance Due: $80.64 Page 1 of 1 CITY OF TIGARD RECEIPT 112_ . 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TICARD Project Name: Brain Reed Site Address: 14173 SW 155TH TER of`67A7e9-z-- Receipt Number: 412304 - 08/11/2017 I CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID MEC2017-00608 Fuel Piping 230-0000-43102 $14.15 MEC2017-00608 12%State Surcharge-Mechanical 100-0000-24001 $10.80 MEC2017-00608 Minimum Fee Adjustment-Mechanical 230-0000-43102 $75.85 Total: $100.80 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 063833 CASHIER USER109 08/11/2017 $100.80 Payor: J&M Contractor Service Rebecca Langston Total Payments: $100.80 Balance Due: $0.00 Page 1 of 1