Permit Support Document (21) 6w:.- RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCT 1 7 2017
. . s
Request for Permit Action
IN
DIVISION
BUILDING CITY OF TIGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • v ',,',,, : , :,,
,
TO: CITY OF TIGARD
Building Division
13125 SW Hail Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: — Owner Applicant n Contractor City Staff
— -
(leek(/)one
REFUND OR Name:
/7
INVOICE TO: (Business or Individual) 5 itittotw kai Individual) -J)
Pt
t A jR
Mailing Address: SZ Li ki
City/State/Zip: R.Y114-14..A--(;(--t (12-- (--7. . ::/7I.-
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED V):
11. / CANCEL/VOID PERMIT APPLICATION.
2 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 #: P1,44,4-1,0,1 4 — CO /0 -1
Site Address or Parcel#: 9'-.9-/0 Nit) I Litta 0 tt
Project Name:
Subdivision Name:
Lot#:
EXPLANATION; „ * ' l' ' (J1 ...I 1,171,c (A).0
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Signature: - ' ; ,,,, . --I
Date: 1 Li /U7-1
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Print Name:
1.Refund Polic'
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• Not more than 80`i,.of the application or plan review fee when an application is withdrawn or canceled before review effort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. 702 50 — -,-S—f*CV '-' /9C SC
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FOR OFFICE USE ONLY
.,:e t*LIELAdmin: Date Bt' EMEIMNEM171,4=1111ffel
Refund Processed: I Date ' Apr, By Ai” — Invoice Processed: Date
1
_ i
Permit Canceled: IMMIM, 7 B, Parcel Tag Added: Date ---- By
-1:\Building\Forms\RegPermitAction_ 231,.cloc.
V
TIGARD
November 20, 2017 City of Tigard
3 Mountains Plumbing
524 N Tillamook St., #102
Portland, OR 97227
Re: Permit No. PLM2017-00404
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9710 SW London Ct
Project Name: Wagner
Job No.: N/A
Refund Method: ® Check#226715 in the amount of$64.96.
0 Credit card "return"receipt in the amount of$
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 cancelled. 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
111
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development en
permit
application fees. Receipts, documentation and the Reque tforPermitActionform if and building
lig ble)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: 3 Mountains Plumbing
524 N. Tillamook St., #102 DATE: 11/8/2017
Portland, OR 97227 REQUESTED BY:
Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 413135
10/3/2017 Case#: PLM2017-00404
Date:
Pay Method: CreditAddress/Parcel: 9710 SW London Ct
arProject Name: Wagner
EXPLANATION Per applicant's request as job was cancelled. Refund 80%of permit fees.
®. se4ixQ9 Ab st�Sd a• a 0°6 E '`ir":'�"1�.'e a} sE rN �E5 I�E » -�r� .r"'
S "�y„sart;' 31 $,
5''ib 8'i"k.`xM07
0�Py�umt�bin mo230-0000-4310112%State Surchar•a
100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS:
SIGNS .;. SATE:
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
r FOIL T'IIEMK'SYST M
Case Refund Processed: AD1 ISTRATI(�1 Ur.,QNL
Date: r er/cr "
1:\Building\Refunds\RefundRequest.dce x 09/01/2010
714 CITY OF TIGARD
■ e , 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
TIGARD
Project Name: WAgner
Site Address: 9710 SW LONDON CT
Receipt Number: 416579 - 04/06/2018
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
PLM2017-00404
$-64.96
Total: $-64.96
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Check CASHIER ID RECEIPT DATE RECEIPT AMT
226715
Payor: 3 Mountains Plumbing DROWSE 04/06/2018 $-64.96
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD
1111 a ' 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
503.639.4171
TIGARD
Project Name: WAgner
Site Address: 9710 SW LONDON CT ,,rr��
C/2l61/ t----
Receipt Number: 413135 - 10/03/2017
CASE NO. FEE DESCRIPTION
PLM2017-00404 REVENUE ACCOUNT NUMBER
Water Service PAID
PLM2017-00404 12%State Surcharge-Plumbing 230-0000-43101
PLM2017-00404100-0000-24001 $62.54
Minimum Fee Adjustment-Plumbing $8.70
230-0000-43101
$9.96
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE
Credit Card ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Payor: RaeLynn Erhardt 00726G PUBLICUSER107 10/03/2017
$81.20
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1