Permit Support Document (55) 08/21/2017 13:35 5036226612 SANDY RIVER ACCTG PAGE 01/02
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City of Tigard • COMMUNITY DEVELOPNIENT DEPARTMENT ,-
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Re uest for Permit ActionRECI
f l i_,A R F) 13125 SW Hall Blvd. -Tigard, Otcgun 97223 ' 503-718-2439 -www.tigard ox•gT1f, �. 7Oi 7
TO: CITY OF TIGARD (.IVY ) TIS
ARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 Tigardl3uildingPcrzaits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant rxt Coot.:iLLt;t ❑ City Staff
f;hcck(✓)ort.
REFUND OR Name:
INVOICE TO: (Business or Individual) ,xj._L C.4
Mailing Address: --'`o box_ `5DS
City/State/Zip: ___frs.lytv3n9, ciloc,c1
Phone No.: Fj 3 3. ..
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED V):
E CANCEL/VOID PERMIT APPLICATION_
1 rtftFUNID PERMIT MES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach cane fcc uchedule and provide explanation below).
❑ RIMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: 0x1-1-005653
Site Address or Parcel#: 11'1.66 S t,7 t„L. k
Project Name: '-i +;17 `u.re.b
Subdivision Name: R - J Lot#:
EXPLANATION: -f
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qac � �• � ‘' � tw " % DY._ �1}02l
ct_ \l'e_, LIM\ h* \Y• 6.Q 4•_ E� ‘ ' . ' r • - - it a • • t. .
Signature: _, Al//` -. Date: 9-. l-'1
Print Name: t(r\('., ,,,,-
1. 'I'hc city',Community 1)cuvlirinucut l)iuutn,Duildi iy Off-mild rrr t;iiy I,lineup may authorize rhe refund of:
• Any fee which was err meously paid or collected.
• Not inure than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
Incl lrcLii crl1Lmdccl_
• Not more than 80%of the application or permit fee for i,;tticci permits prior to any inspection requests. •
2. All refunds will be returned to the original payer in the form of a cheek via US postal service.
3. ('lease allow 3-4 wmcka Cut lntrct;nnir,k rcfund rtclu�c%15. s- ./1?
— rge - /"/• V'
6, 7y x• 39 c /' 3_5-
hoz-%.- J5 % 33 / S'2'
FOR OFFICE. I TSE ONLY
Route to S'r.Admin: Dna,. gr/At liar 11 Route to RocorcIa: 1.3aee3f° r/- 8 41t�, i
Refund Procesed: Dare j y /7 By 41 Invoice Processed: Data By
Permit Canceled: Date /y//7 By..0'1"; Parcel Tag Added: Date By
1:\th..ddi„h\I2.,rrnr\11cq PcrmitAction U'..314.b c
IN
TIGARD
September 21, 2017 City of Tigard
The Power Works LLC
Attn: Eric Martin
PO Box 1528
Boring, OR 97009
Re: Permit No. ELC2017-00593
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11765 SW Walnut St
Project Name: Drake
Job No.: N/A
Refund Method: ® Check#226189 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.
0 Trust account"deposit"receipt in the amount of$ .
Comment(s): Per applicant's request as job was completed under a minor label.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
<1;Y;447-76)---j_e_,
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
1
7
_ .4City 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 Reque t 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: The Power Works LLC DATE: 9/14/2017
Attn: Eric Martin
PO Box 1528 REQUESTED BY: Dianna Howse
Boring, OR 97009
TRANSACTION INFORMATION:
Receipt#: 412235 Case#: ELC2017-00593
Date: 8/8/2017 Address/Parcel: 11765 SW Walnut St
Pay Method: CreditCard Project Name: Drake
EXPLANATION: Per applicant's request as inspector informed them to use minor label as he will not
inspect an empty residence with an alarm. Refund 80%of permit fees.
.,
, 4)a v trr , . 4 ,6. fi '. xE, _ , s `;tf _.a�F�a�'':� �r® ��3.>p sR `F5 .' " €a€ a4"` a r §a
t� d(s ; > Iv `` t..p: ±�e r ' ; . �csm rebft_ iaw „ �r� .�� $44.94Ees�ical Permit 220-0000-43103 .��
12%State Surchar:e 100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SI RES/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 p y}vv
Case Refund Processed: Date: 3 a3 1.1--- By: � �•
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
riI
CITY OF TIGARD RECEIPT
a 13125 SW HaII Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Pro Plumb
Site Address: 11765 SW WALNUT ST
Receipt Number: 416298 - 03/23/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00593 $-50.33
Total: $-50.33
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 11765 DHOWSE 03/23/2018 $-50.33
Payor: The Power Works LLC
Total Payments: $-50.33
Balance Due: $50.33
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CITY OF TIGARD RECEIPT
q
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIG ARD
Project Name: Pro Plumb
Site Address: 11765 SW WALNUT ST
Receipt Number: 412235 - 08/08/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00593 Branch Circuits wo/Purchase Service or 220-0000-43103 $56.18
Feeder
ELC2017-00593 12%State Surcharge-Electrical 100-0000-24001 $6.74
Total: $62.92
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 00838G PUBLICUSER182 08/08/2017 $62.92
Payor: Kim Hoecke
Total Payments: $62.92
Balance Due: $0.00
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