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PFI2017-00229 A City of Tigard November 20, 2017 Black Rock Underground LLC 267 NE 34``'Place Hillsboro, OR 97124 Re: Permit No. PFI2017-00229 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 13020 SW Summit Ridge St Project Name: Anderson Job No.: N/A Refund Method: ® Check#226728 in the amount of$300.00. ❑ Credit card "return"receipt in the amount of$ 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): Refund 100% of application fee as work was on private property and not in the right of way. 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 0 www.tigard-or.gov C ° City of Tigard 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 PermitAction 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: Black Rock Underground LLC DATE: 11/6/2017 267 NE 34hPI Hillsboro, OR 97124 REQUESTED BY: Dianna Howse JG TRANSACTION INFORMATION: Receipt#: 413310 Case#: PFI2017-00229 Date: 10/12/2017 Address/Parcel: 13020 SW Summit Ridge St Pay Method: Check Project Name: Anderson EXPLANATION: Refund 100% of application fee as work was on private property and not in ROW. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee )�xarri le: 230009_9q-43104 $At punt PFI Permit Fee 100-0000-43114 $300.00 TOTAL REFUND: $300.00 APPROVALS: SIG E DATE: 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 FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT S 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Anderson Site Address: Receipt Number: 416582 - 04/06/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00229 $-300.00 Total: $-300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 226728 DHOWSE 04/06/2018 $-300.00 Payor: Black Rock Underground LLC Total Payments: $-300.00 Balance Due: $300.00 Page 1 of 1 CITY OF TIGARD RECEIPT 0 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Anderson Site Address: Receipt Number: 413310 - 10/12/2017 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00229 PFI Permit Fee 100-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1408 LSMITH 10/12/2017 $300.00 Payor: BLACK ROCK UNDERGROUND, LLC Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 City of Tigard • COmmuNITY DEVELO PMENT DEPARTMENT _ Request for Permit Action 13125 SX Hall Blvd. Tigard, Oregon 97223 . 503_718_2439 . ���.ri- an ON / TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Cheek(V)one. REFUND OR Name: INVOICE TO: (Business or lndwidual) Wac'k LLC Mailing Address: (..7 /(�� 3,(+L PL. City/State/lip: A;IIS 4-ro a 7t 2Y -- Phone No.: 503- g9.&- g-7g0 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED {✓): 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: PFN2017-60.229 Site Address or Parcel #: 13 0,2 0 S t.3 tAwt at s�- '►`oRQ� S'i' Subdivision Name: Lot#: EXPLANATION: d i k � (2O�. L lv vat ;s l4 t o #�a-k Signature: Date: 10110 1 -7 Print Name. Refund Policy 1. 1 he 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. Plcase allow 3-4 weeks for processing refund requests. Route to SN=s admin: Date Bir Route to Records: Date / B Refund Processed: Date 'y / B Invoice Processed: Date BN Permit Canceled: Date �/ / B Parcel Ta added: Date B t:\RuildinG�1'nrms�lteyl'crmit�ctinn_o9231 .doc