Permit Support Document (31) RJ)::iiVED
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TO: CITY OF TIGARD fG I
Building Division 0
13125 SWC'Hall Blvd., Tigard, OR 97223 vie -----
Phone: 503-718-2439 lax: 503-598-1960 TigardBuildingPerrnitsCttgard-or.govv
FROM: 1 I Owner I I -Applicantont.ractor I I City Staff
(:heel:(✓)one
REFUND OR Name: j�.� '
INVOICE TO: niusinc or Ind. i_lal , / ci-66-1200 a9901..��¢'t//�j�/�
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Mailing Address: t O x. 36) natrofy\-K
City/State/Zip: 0/46144,7145- ^- "lT49/S.--
Phone No.: �/ e6-0 -�ti � 3YL't/
PLEASE TAKE ACTION FOR THE ITEM(S) >i e
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A....._ 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 PERIIvIIT (do not cancel permit).
Permit #: Paiij 4°/ ��06o/it
Site Address or Parcel #: /��Y/� T(/ l/ l/ g?/41 44/
Project Name: 6'/)(�`�
Subdivision Name: Lot#:
EXPLANATION: J , r _drip, g4/40, i�
Signature: /
Date: j///0/0 12
Print Name: '/ /�e/,Da, // f
Refund Policy � '!
1. The city's Community Development Director,Building Official or City I.ngineer 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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°a of the application or permit fee for issued permits prior to any inspection requests.
2. .All refunds will be returned to the original pater 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 Admin: Date By Route to Records: Date /,,225 /, By e -
Refund Processed: Date /ie /9 By 4, Invoice Processed: Date By
Permit Canceled: Date/ /1? By J r Parcel Tag Added: Date By
I:\Building\Forms\RegPerrnit3ctiorf 092314.doc
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TIGARD
City of Tigard
January 24,2019
Jack Howk Plumbing Co.
PO Box 2830
Clackamas, OR 97015
Re: Permit No. PLM2018-00504
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14270 SW 97th Ave.
Project Name: Ransdell
Job No.: N/A
Refund Method: ® Check#231037 in the amount of$64.96.
❑ Credit card"return" receipt in the amount of$ .
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 cancelled. Refund 80%of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4k-'
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
CITY OF TIGARD14 RECEIPT
a, . 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: RANSDELL
Site Address: 14270 SW 97TH AVE t AZI__
Receipt Number: 421253 - 01/25/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2018-00504 $-64.96
Total: $-64.96
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 231037 DHOWSE 01/25/2019 $-64.96
Payor: Jack Howk Plumbing Co.
Total Payments: $-64.96
Balance Due: $64.96
Page 1 of 1
CITY OF TIGARD1,111 RECEIPT
.a s 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Trt;AJC_D
Project Name: RANSDELL
Site Address: 14270 SW 97TH AVE /2-1- 1"04---
Receipt
j^/Receipt Number: 420156 - 10/29/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2018-00504 Sanitary Sewer 230-0000-43101 $62.54
PLM2018-00504 12%State Surcharge-Plumbing 100-0000-24001 $8.70
PLM2018-00504 Minimum Fee Adjustment-Plumbing 230-0000-43101 $9.96
Total: $81.20
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 061597 PUBLICUSER109 10/29/2018 $81.20
Payor: ARS PORTLAND PERMITS
Total Payments: $81.20
Balance Due: $0.00
Page 1 of 1