Permit Support Document (24) 02/22/2018 15:02 5032551966 CAPITOL ELECTRIC PAGE 01
RECEIVED
7FEB 2 2 2018
AX
DCit ofTigard COMMUNITY 1EVPLOPM A1i FNT
i� rtiRD uest for Permit Act VIN Divist
1ci A k 13125 SW.Hall Blvd. -Tigard, Oregon 97223 •503-718-2439 •www.tiy>ard-or..goyr
Nilifiwis
TO; CITY OF TIGARD
Building Division ,, oiD
13125 SW Hall Blvd.,Tigard,OR 97223 2/i 3 /�� ,<.,f/f /4"---
Phor].e; 503-718-2439 Fax: 503-598-1960TigardBuildingFermirs@tigard-or.ggems
FROM: 0 Owner
Check(1)ane ElApplicant ❑ Contractor ] City Staff
REFUND OR Name:
INVOICE TO: ( isineNs or individual) Al i 0 L D I ? , at_ „S
Mailing Address: ! (4Q 1 E '
Ciry/State/Zi.p: 1 if I iii 9 / • 221
Phone No.: I - —q A d'r
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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel.permit).
Permit#: EL... 20 - it
Site Address or Parcel#: j° :5 VV ,i _�
Project.Name: / r �� fC(,rL.
Subdivision Name:
Lot#:
EXPLANATION: i 0 A ' .11_ 1/, A' /J 4,m / — p / 1- - le ', /#,
Signature:
/ �/.�.�
i . at
• Date:
Print Name: .1 Z i,� 4 . ./Jay'
_46A2- j_g___
A,cfund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of;
• Any fcc 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• Not more than 80%of the application or plan review fee when an application is withdrawn or,canceled before review effort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 fcc fur 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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- OIt OFFICE I_151::ONLY
Routc to 5vs Admin: Data B Route to Records: Date
Refund ProcCsscd: Date 3 r q'%r —- '2 ani
�f' B -�„ Invoice Processed: Date B
Permit Canceled: Dare ,? — Parcel Tag Added: Date
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111111
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TIGARD
City of Tigard
March 1, 2018
Capitol Data&Communications
Attn: Christina Williams
11401 NE Marx St
Portland, OR 97220
Re: Permit No. ELR2017-00211
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9585 SW Washington Square Rd
Project Name: Playlive
Job No.: N/A
Refund Method: ® Check#227693 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 cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
, (2,'12)4-le7-JC---
Dianna Howse
Building Division Services Supervisor
Enc.
1
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov