Permit Support Document (18) frill 2x4114— SE251
City of Tigard • COMMUNITY DEVEI.OPMENT :P r")i , RTNIIEN frp. L,RI tEOCtTi
III g
Request for Permit Action ...„......
TIG AR n 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-c&"1-001C,' DIViS;;(14-ift:
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: 0 Owner tikj Applicant 2 Contractor 0 City Staff
Chcck(,)onc
REFUND OR Name:
INVOICE TO: (Business or incloiduar) /. * ? Dv - 4- , ., 1 C • Bic
I matt:.. • 1 -I
Mailing Address: 21.250 Nicwookij Dr Sk /CIO
City/State/Zip: Alii•tla re-l-i-a, GP.i 3c00S—
Phone No.: 17o 772- 34 ti 2..._____________
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED(1):
CANCEI/VOID PERMIT APPLICATION.
2 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR.FEES DUE(attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: LCg()17
Site Address or Parcel#: I 06(o 6- 5W Cas c4esta. 131 vci
Project Name: • '7 o S R Lt$ Int Ai
Subdivision Name:
Lot#:
EXPLANATION: , a . I— . a . ii * • .... er - c:Ire-
0 I .• • a a C ...v •
,
I \
Signature: / ,Q...11 i 'agk --...._ ...,- ''.-2 Date: Cija6.1/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. — ..s-'.0. f-k = /2 -7. 3 - 4', , to
7/. P. —' '16E'
7 ',.i.k,k',,,,• •y4 le; .. FOR OFFICE USE ONLY
ER-JRoute to Sys Admin. Date Br Route to Records: Date 9‘ te" Bs . r- P
fHrid Processed: Date 9//e By i / Invoice Processed: Date By,
Perrnit Canceled: ,_ Date// 6 /2 _ By .0.17 Parcel Tag Added: bare
l
Br
I),ZiAny,Nrms,,RcciPercnnAcurm 23.ddoc
Scanned by CamScanner
,' q
TIGARD
City of Tigard
November 20, 2017
Lin R Rogers Electrical Contractors Inc.
2050 Marconi Dr., Suite 100
Alpharetta, GA 30005
Re: Permit No. ELC2017-00492
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10065 SW Cascade Blvd
Project Name: Toys R Us
Job No.: N/A
Refund Method: ® Check#226760 in the amount of$56.98.
❑ Credit card"return"receipt in the amount of$
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 work was already performed. Refund 80% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
kalk
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
III
z 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 DATE: 11/8/2017
Contractors Inc.
2050 Marconi Dr., Suite 100
Alpharetta, GA 30005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 411524 Case#: ELC2017-00492
Date: 6/30/2017 Address/Parcel: 10065 SW Cascade Blvd.
Pay Method: CreditCard Project Name: Toys R Us
EXPLANATION: Per applicant's request as work was already performed. Refund 80%of permit fees.
iKVISA �� O
.1..C. 4.4.!;4 „,
."�rs.'�.�� ,.'=F�1�sa�� ' .*- .. „mm•* ys. _a 2 s t S «...
Electrical Permit
220-0000-43103 $50.88
12%State Surchar.a 100-0000-24001 6.10
TOTAL REFUND: $56.98
APPROVALS: SIG TURES/DATE:
If under$5,000 Professional Staff .-‹*V")W7Z2-r-e—
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
iter '” igilltM1V *
xr Case Refund Processed: Date: 0/4F- I By:
G � ,� �.
I:\Building\Refunds\RefundRequestdoc x 09/01/2010
CITY OF TIGARD
141
RECEIPT
a` 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
TtGA1 1)
Project Name: 2017 Toys R Us Toy Mission Project
Site Address: 10065 SW CASCADE AVE
Fu iv'L ,
I Receipt Number: 416574 -
04/06/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00492
$-56.98
Total: $-56.98
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226760
Payor: Lin R Rogers Electrical Contractors Inc DHOWSE 04/06/2018 $-56.98
Total Payments: $-56.98
Balance Due: $56.98
Page 1 of 1
11 CITY OF TIGARD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: 2017 Toys R Us Toy Mission Project
Site Address: 10065 SW CASCADE AVE
of/G(itie9z,
I Receipt Number: 411524 -
06/30/2017 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00492 Branch Circuits wo/Purchase Service or
Feeder 220-0000-43103 $63.60
ELC2017-00492 12%State Surcharge-Electrical
100-0000-24001 $7.63
Total: $71.23
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 030890
Payor: Jamal Chehimi PUBLICUSER108 06/30/2017 $71.23
Total Payments: $71.23
Balance Due: $0.00
Page 1 of 1