Permit Support Document (34) 11-27-'17 13:34 FROM- Bear Elect r i c, I nc. 5036781108 T-363 P0001/0001 F-151
City of Tigard . COMMUNIT'Y'DEVELOPMENT DEPARTMEN "
1: N -i-- I Request .
L.
q _ Permit Action
Jii,1l:17
13125 SW Hall Blvd.••Tigard, Oregon 97223.503718-2439 •wViw.rigard-+�, f f,Ir 201� 11
-- ►� 2
TO: CITY OF TIGARD CITY OF TIGARD
Building Division BUILDING DIVISION
13125 SW Mall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax. 503-598-1960 TigardBuildingPermits( tigard-or.gov
FROM: 0 Owncx M Applicant ❑ Contractor ❑ City Staff 0 1 D
Check(✓)one
REFUND OR Name: /z�Z,��
INVOICE TO: {Business or Individual) •
Mailing Address: p() B o X ggcl
City/State/Zip: Dd011 H2O
Phone No.: 50 a- b1(3 - ( 6 6
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1/):
CANCEL/VOID PERMIT.APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below),
❑ INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: E.Le 2,0t1 - 00So
Site Address or Parcel#: Cj 1 S V\. 01,-1"r" P t
Project Name: RN eiVICUrt SOF
Subdivision Name: tt Lot#:
EXPLANATION: V O rl UW(1,5 (LI,ko .
Signature: Date: 11 121 irl
Print Name: t A I ISSO, W I t I1 ist1rY1S
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 cheek via US postai service.
3, Please allow 3-4 weeks for processing refund requests- `/ ''Zr
9 ,5 e.33 420 CS
Route to Sys Admin: Dare // Vi 1 By ,3 7. Route to Records: Date y Ar I3y
Refund Processed: Date i i1"// By Invoice Processed; Date By
Permit Canceled: Date
/2� r 7 By Parcel Tag Added: Dare By
T:\13ui!ding\Forms\RegpermiNciion_09 3]4. c
1111 a
TIGARD
January 18, 2018 City of Tigard
Bear Electric Inc.
Attn: Melissa Williams
PO Box 389
Donald, OR 97020
Re: Permit No. ELC2017-00869
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15678 SW 84th P1
Project Name: Richardson
Job No.: N/A
Refund Method: ® Check#227168 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
0 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 job was cancelled. Refund 80% ofP ermit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/046 ,
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
1111 n
: 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 BequestforPermittActioon form (if pp geering and buildinable) 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: Bear Electric Inc
DATE: 12/28/2017
PO Box 389
Donald, OR 97020 REQUESTED BY:
Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 414018
Date: 11/21/2017 Case#: ELC2017-00869
Pay Method: 11/21Card Address/Parcel: 15678 SW 84th P1
Project Name: Richardson
EXPLANATION Per applicant's request as job was cancelled. Refund 80%of permit fees.
(
Electrical Permit .'
12%State Surchar•e 220-0000-43103 $44.94
100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SIGNATURES DATE:
If under$5,000 Professional Staff
AL-_�i
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
,
Case Refund Processed.
r# �
Date: 11/11527—IAMIN
Bj .
is\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD
a 13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
)11
TIGARD 503.639.4171
Project Name: Richardson
Site Address: 15678 SW 84TH PL
Receipt Number: 416596 - 04/06/2018
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00869
$-50.33
Total: $-50.33
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Check CASHfER ID RECEIPT DATE RECEIPT AMT
227168
Payor: Bear Electric Inc. DROWSE 04/06/2018 $-50.33
Total Payments: $-50.33
Balance Due: $50.33
Page 1 of 1
CITY OF TIGARD
N.__ RECEIPT
• 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Richardson
Site Address: 15678 SW 84TH PL
Die/ (A1 L —
i Receipt Number: 414018 -
11/21/2017 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00869 Branch Circuits wo/Purchase Service or
Feeder 220-0000-43103 $56.18
ELC2017-00869 12%State Surcharge-Electrical
100-0000-24001 $6.74
Total: $62.92
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Credit Card 111284 CASHIER ID RECEIPT DATE RECEIPT AMT
Payor: Melissa Williams PUBLICUSER108 11/21/2017 $62.92
Total Payments: $62.92
Balance Due: $0.00
Page 1 of 1
I