Permit Support Document (36)IC•
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• City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OEC 2017
. Request forCITYOFTIGAR
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q Permit Action
IN
BUILDING DIVISION
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov
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TO: CITY OF TIGARD
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Building Division j2 zeA2
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov ,
FROM: [ Owner 0 Applicant 111 Contractor CityStaff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) TYCO Integrated Security
Mailing Address: 6305 SW Rosewood St.
City/State/Zip: Lake Oswego,OR. 97035
Phone No.: 503-451-2055
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
El CANCEL/VOID PERMIT APPLICATION.
rREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
I
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
[l REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ELC2016-00947
Site Address or Parcel#:
7632 SW DURHAM RD,200, TIGARD OR 97224
Project Name: Allstate
Subdivision Name:
Lot#:
EXPLANATION: Work was inspected and finaled on permit ELR2017-00067
..................... ...
Signature: �`�`,
Print Name: c-, ,,,,..,:- --c) �� Date: 12/04/2017
Tj} elms
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Adrnin: Date By Route to Records: Date r/4 ,,r--- By ?"
Refund Processed: Date (2.-/Z2(/7 By, ' Invoice Processed: Date B
Permit Canceled: Date y
/7 By . arcel Tag Added: Date By
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TIGARD
City of Tigard
January 18, 2018
TYCO Integrated Security
Attn: Tjy Helms
6305 SW Rosewood St
Lake Owego, OR 97035
Re: Permit No. ELC2016-00947
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7632 SW Durham Rd., #200
Project Name: Allstate
Job No.: N/A
Refund Method: ® Check#227209 in the amount of$67.20.
❑ Credit card "return"receipt in the amount of$
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 job was completed under ELR2017-00067.
Refund 80%of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,K61 -2(/,e7e_.7—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
11111 a
City of Tigard
TicnkD Accela Refund Request
This form is used for refund requests of land use, development engineering
application fees. Receipts, documentation and the RequestforPermitAction rm (if aand pplicable)ble) ust
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: TYCO Integrated Security
DATE: 12/28/2017
6305 SW Rosewood St
Lake Oswego, OR 97035 REQUESTED BY:
Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 407944
Date: 12/16/2016 Case#: ELC2016-00947
Pay Method: 2/16/201 Address/Parcel: 7632 SW Durham Rd,#200
reditCard
Project Name: Allstate
EXPLANATION: Per applicant's request as work was completed under ELR2017-00067. Refund 80%of
permit fees.
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1�.Zr „ g�v 4 :„ -,t.,1, a a � }a � rrm sk 1.a'4.ti' t rxa �t�w1.I ,e tt � s�����. -'04.:3415$441;�Electrical Permit 220-000043103 $60.00
120/o Surchar:e
100-0000-24001
7.20
111.11111111111111111111111......
TOTAL REFUND: $67.20
APPROVALS: SIGNA _ RES DATE:
If under$5,000 Professional Staff _. at
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
dY1" r „ fm,rgi d i tis 4 _ t fi s , ICase Refund Processed: Date: SJ B :
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD
II RECEIPT
i 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
T f G\ .l:}
Project Name: Allstate
Site Address: 7632 SW DURHAM RD 200
Receipt Number: 416597 04/06/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2016-00947
$-67.20
Total: $-67.20
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 227209
Payor: TYCO Integrated Security DROWSE 04/06/2018 $-67.20
Total Payments: $-67.20
Balance Due: $67.20
Page 1 of 1
CITY OF TIGARD RECEIPT
i 2 ' 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Allstate
Site Address: 7632 SW DURHAM RD 200
IReceipt Number: 407944 - 12/16/2016 I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
ELC2016-00947 Signal circuit or Limited Energy Panel 220-0000-43103
ELC2016-00947 12%State Surcharge-Electrical $79.00
100-0000-24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 073095 PUBLICUSER134 12/16/2016
Payor: Autumn Jones $84.00
Total Payments: $84.00
Balance Due: $0.00
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