Permit Support Document (53) RECEIVEJ)
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City of Tigard • COMMUNITY DEVTzL0 /NT DEPARTMENT AUG 2 l ?O/7
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Request for Permit Action 1IN ,
T I G A R D 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439• www.tigard-or.gov .r J 15111
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 ❑ City Staff
Check(E one
REFUND OR Name:
INVOICE TO: (Business or Individual)
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Mailing Address: /00E a—notaz in; /2riki
City/State/Zip: NeL1�bg,� l 0r2 97 ia3� `�
Phone No.: $03 ,S',.38 - /9(7O
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( E5 :
►lCANCEL/VOID PERMIT APPLICATION.
)!t 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#: MECeRo I Oo s q-(
Site Address or Parcel#: /a 76,,; (3,„) 0,, 14),,,r',767 �, DoQ 7 7aZ V
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Project Name: /V�(o
Subdivision Name: Lot#:
EXPLANATION: C1 i'I'1+ Geo celled-in fano' f7,
Signature: ,/ :_-�r Date: V60/020/7
Print Name: (r`fly ai)y
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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'a
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FOR OFFICE USE ONLY
Route to Sys Admin: Date ' Al 1 :y 'I Route to Records: Date 3 0,13s 3 /- By s
Refund Processed: Date = /y7i 7 By . •r Invoice Processed: Date By
Permit Canceled: Date— �y//7 By ,r, Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 2314. oc
1111 q
TIGARD
September 21, 2017 City of Tigard
Four Seasons Heating&Air Conditioning
Attn: Christina Riggs
1005 Industrial Parkway
Newberg, OR 97132
Re: Permit No. MEC2017-00548
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12762 SW DaVinci Ln
Project Name: Fong
Job No.: N/A
Refund Method: ® Check#226149 in the amount of$80.64.
0 Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
0 credited to your account by the company that issued your card.
Trust account"deposit"receipt in the amount of$
Conunent(s): Per applicant's request as job was cancelled. Refund 80% ofP ermit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
rt(13 -0742-/-c_
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
lit
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 forPermit 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: Four Seasons Heating&Air DATE:
9/14/2017
Conditioning
Attn: Christina Riggs
1005 Industrial Parkway REQUESTED BY: Dianna Howse
Newberg, OR 97132
TRANSACTION INFORMATION:
Receipt#: 412000 Case#: MEC2017-00548
Date: 7/27/2017 Address/Parcel: 12762 SW DaVinci Ln
Pay Method: CreditCard Project Name: Fong
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees.
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Mechanical Permit 230-0000-43102
00
12%State Surchar•e $72.64
100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIG S/DATE:
If under$5,000 Professional Staff -44r If
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
I ,, .
Case Refund Processed: Date: 3/ .Y // By: I 1i ,
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
ii
* 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Fong
Site Address: 12762 SW DA VINCI LN sNb
Receipt Number: 416299 - 03/23/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2017-00548 $-80.64
Total: $-80.64
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226149 DHOWSE 03/23/2018 $-80.64
Payor: Four Seasons Heating&Air Conditioning
Total Payments: $-80.64
Balance Due: $80.64
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111111
CITY OF TIGARD RECEIPT
■ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T f[;.,\,1.-1
Project Name: Fong
Site Address: 12762 SW DA VINCI LN
I Receipt Number: 412000 - 07/27/2017
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
MEC2017-00548 Air Conditioning 230-0000-43102
MEC2017-00548 12%State Surcharge-Mechanical $10.80
MEC2017-00548 100-0000-24001 $10.80
Minimum Fee Adjustment-Mechanical 230-0000-43102 $43.25
Total: $100.80
PAYMENT METHOD CHECK# CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 07559G PUBLICUSER107 07/27/2017
Payor: Diane M Hahn $100.80
Total Payments: $100.80
Balance Due: $0.00
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