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Request for Permit Action CITY(If: liGARD
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'1'0: CtlY OF TIGARD
Building Division
13125 S\\ Idl 1172., 1*igard, (7111(.. trI225
Phones 503-718-2139 FaN: 50-598-19On 1i54rd.131ililine7'rrchslititil.„!:(trd-or.cov
FROM: (1. vu r 1 \bola:ant u Ecity 71-411-
REFUND OR N.rump
INVOICE TOClackamas Electric, Inc,
:
Math:1d ,-Nxicirdss: B0 Box 51
Gay/Statd//tp: Beavercreelo OR 97004
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Phone Na,: (503) 632-2420
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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P7ermit F.A.C2017-00701
Silt \LIcirt-ss P,uvri 14915 SW 72nd Avenue
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EXPLANATION: Used wrong address in error for the permit application.
1.):,11c: October 30, 2017
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TIGARD
November 20,2017 City of Tigard
Clackamas Electric, Inc.
PO Box 51
Beavercreek, OR 97004
Re: Permit No. ELC2017-00701
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14915 SW 72nd Ave.
Project Name: Rivas
Job No.: N/A
Refund Method: ►4 Check#226737 in the amount of$156.71.
❑ Credit card "return"receipt in the amount of$
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 wrong address was used on permit. 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
N
111 City of Tigard
rlGARt) 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: Clackamas Electric, Inc. DATE:
P11/8/2017
O Box 51
Beavercreek, OR 97004 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 412977
Date: 9/25/2017 Case#: ELC2017-00701
Address/Parcel: 14915 SW 72nd Ave.
Pay Method: CreditCard
Project Name: Rivas
EXPLANATION: Per applicant's request as wrong address was used on permit. Refund 80% of permit
fees.
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�4n ,: a g= ,rZif ;4-*A :,Electrical Permit
220-0000-43103
12%State Surcharge $139.92
100-0000-24001 16.79
TOTAL REFUND: $156.71
APPROVALS: SI
/DATE:
If under$5,000 Professional Staff 'j ,
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
7FORID l�%IARl SY:S VOli iNt$T' tAT#C ft1;i, SO;Q1 L'
Case Refund Processed: y��/4°
Date:
��� By: 101^1.‘---
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I:\Building\Refunds\RefundRequest.doc x 09/01/2010
TOF
14 a 13125CIY SW Hall Blvd.TIGARD,Tigard OR 97223 RECEIPT
- 503.639.4171
Project Name: PCS-Rivas
Site Address: 14915 SW 72ND AVE
CASE NO.
Receipt Number: 416577 - 04/06/2018
FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00701
$-156.71
Total: $-156.71
PAYMENT METHOD CHECK# CC AUTH.CODE
ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226737
Payor: Clackamas Electric Inc. DROWSE 04/06/2018 $-156.71
Total Payments: $-156.71
Balance Due: $156.71
Page 1 of 1
114 CITY OF TIGARD
13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
TIGARD
Project Name: PCS-Rivas
Site Address: 14915 SW 72ND AVE
Receipt Number: 412977 - 09/25/2017
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00701 Services or Feeders-200 amps or less
ELC2017-00701 Branch Circuits w/Purchase Service or 220-0000-43103 $ .
Feeder 220-0000-43103 $74.200
ELC2017-00701 12%State Surcharge-Electrical
100-0000-24001 $20.99
Total: $195.89
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 05315G
Payor: LOLITA GALLAMORE PUBLICUSER109 09/25/2017 $195.89
Total Payments: $195.89
Balance Due: $0.00
Page 1 of 1