Permit Support Document (55) R
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City of Tigard. • cOvtvlt N l'isr- I)L1'I"l.<1l':11-;NT D1.PARTMLIN°'r NOV 22 2017
Request for Permit Action CITYOFTIGARD
CIfaAKC7 13125 " Mall 131,d. • `liga d, t)ret on 9 223 •• 503-71K-2439 • ��,�z,tit,tir t'cY af! �iDS
ION
TO: CITY OF TIGARD
Building Division
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13125 SSC"I fall BR u.,`Tigard,OR 97223
Phone: 503-?18-243x9 Fax: 503-598-1960 'li"gardBuildint;Permits�ci'?tigard-«r.gov� ����'��E
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FROM: E Owner
ci,ret ,; , A.phlic�intCe>ritracrur City Staff
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REFUND OR Name:
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Citv/`hate:/7„ip: ��l ( 4 'h
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PlittTle NO.: f= _ 2
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
~� CFANCl;l�/V )ID P1?RMI] APPLIC\1 ION,
RI:.,1.NI) PERMIT FEES ES (attach copy of original receipt and provide explanation below).
1\\Ft)I( 1', IA)R 1:1 1,S DI I, (attach case fee schedule and provide explanation below).
H RIaMC)VE/Rl;P1,ACh.CC)N'1'RACl"C_)1( ON PER 1IT (do not cancel permit).
Permit II:
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Sire .Address or Parcel t<:: ��� ��":� –) v , --
Project Name:
Subdivision Name: ,, . ,„ ( t .) r
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EXPLANATION t , ,*,
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Print Name: 'I-41'# �%�
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I. The t u) s Community Drivel,il)rn ni 1)iruclor,13trilctiug Official iir City Engineer may authorize tlhe refund oi:
• Any fee which ii 15 CO'UI@"uusl)paid or tsollecxeci.
• Not ntnrt than 80'ic of the application or plan review fee when an application is taithdrawii or canceled Ix-fore review effort
has been expended.
• Not rain:than hI o of ilu ap;thcarii"n or permit fee for Isiaaid permits prior LO any inspection requests.
'„All refunds will he returned to the original payer in the form of a check 514 1'S pt, tai se ser.litec.
3 Please allow.1 1 weeks for procvi,sinA reek ud rcottests.
(Ore re, ,69 ,?e-A,/6
FOR OFFICE USE ONLY
Rome to 4t Adrvt r Date By
Cts icy)Sys Processed: Rout•to Ri ordi, T}i t, . I [;, /�I�'
Date: /Z l;
> R��r. lnseticz•la<xc55d t)ttc�
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Permit Canceled:eied: R)uc By
T.AI3,i'.atinc ,l"units`Reif t rota l,.t JX2,1 1.4c Parcel R 3t ,AcldCtl: DAL(' RV
111 V
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TIGARD
January 18, 2018 City of Tigard
Evergreen Gas Inc.
Attn: Brittany Noblin
PO Box 388
West Linn, OR 97068
Re: Permit No. MEC2017-00867
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for
following: the
Site Address: 15048 SW 91"Ave.
Project Name: Hanners
Job No.: N/A
Refund Method: ® Check#227178 in the amount of$80.64.
0 Credit card "return"receipt in the amount of$
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% ofermit fees.
es.
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
III tl
n City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development en
ermit
application fees. Receipts, documentation and the RequestforPermittA tioeeonnlg fformand(if a�bulicagble )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: Evergreen Gas Inc.
DATE: 12/28/2017
PO Box 388
West Linn, OR 97068 REQUESTED BY:
Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 413698
Date: 11/2/2017 Case#: MEC2017-00867
Pay Method: 11/2/201 Address/Parcel: 15048 SW 91St Ave.
CreditCarProject Name: Hanners
EXPLANATION Per applicant's request as customer cancelled job. Refund 80%of permit fees.
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`u ,r u»� y ra 1.xc ,
12%State Surchar..e 230-0000-43102 $72.00
100-0000-24001 8.64
miNMENIMINIMMINIMIIIIIIIIIIIImim
TOTAL REFUND: $80.64
APPROVALS: SI iiiiiir 'ES DATE:
If under$5,000 Professional Staff f' T=/r
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: TIP $E;'i ,t q, {z
Date: E1�/�' B : ��;�
I.\Building\Refunds\RefundRequest.doc x 09/01/2010
IN
CITY OF TIGARD
s13125 SW Hall Blvd.,Tigard OR 97223 RECEIPT
- 503.639.4171
T 1CARD
Project Name: Hanners
Site Address: 15048 SW 91ST AVE
I Receipt Number: 416
594 -
04/06/2018 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
MEC2017-00867
$-80.64
Total: $-80.64
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 227178
Payor: Evergreen Gas Inc. DHOWSE 04/06/2018 $-80.64
Total Payments: $-80.64
Balance Due: $80.64
Page 1 of 1
CITY OF TIGARD
�--
RECEIPT
II
sr • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Hanners
Site Address: 15048 SW 91ST AVE
Receipt Number: 413698 - 11/02/2017
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
MEC2017-00867 Gas Fireplace
MEC2017-00867 Chimney/Liner/FlueNent 230-0000-43102 $33.39
MEC2017-00867 Fuel Piping 230-000043102 $23.32
MEC2017-00867 12%State Surcharge-Mechanical 230-0000-43102 $14.15
MEC2017-00867 Minimum Fee Adjustment-Mechanical 100-0000-4 $19.8
230-0000-431310102 $194
.14
Total: $100.80
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID
Credit Card CASHIER ID RECEIPT DATE RECEIPT AMT
05168D PUBLICUSER107 11/02/2017
Payor: William Belden $100.80
Total Payments: $100.80
Balance Due: $0.00
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