Permit Support Document (26) 02/15/2018 14:00 5032551%6 CAPITOL ELECTRIC PAGE 01
City of Tigard * COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
IN * Request for Permit ActionFEB2018
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T i ;ARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.ti;ard�o sL"ITY j(a�j={D
TO: CITY OF TIGARD
Building Division
V 0 1 0
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits a tigard-or-gav /2/i/.-
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 11, D,,. i� 2. 11 f i Ai
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Mailing Address: 19 4 DI RE MakX
City/Spite/Zip: 2
Phone No.: _Sin- -28S-414V
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (s"):
4 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#: 2-00 - 0025g
Site Address or Parcel#: IDIda d/ /!)i , Ire, a
Project Name: el ' > i -- � , i,1 / L
Subdivision Name: f� J^,, Lot#:
EXPLANATION: QO (Jup U►'/��eI'- CLC bet't. t, )4 I a cis. i on,.
Signaturc: _ .li_ . LX..(J,2J74zb Date: ) _ ' I if
Print Name: AIM,/% 4 I. OAS
Refund Policy
1. The city's Community Development Director,Building Official.or.City Engineer may authorize the refund of
• Any Foe which'vat 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• Not more than 80%of the application or plan review fee when an application is withdrawn or,canceled before review effort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 mote than 80%of the application or permit fee for issued permits ptiur to any.inspection requests.
2. AU 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. 75-.c'-i - e., , e1-Z) .� /5; 11
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FOR OFFICE USE ONLY
Roux to Sat Adnan: Date . Route to Iteeorcls: Date �� gt,
Refund Processed: Date c ..M/Yit 13 _S/] Invoice Processed: Date By
Permit Canceled: Date ,;2q 4 By Pared Tag.Added: Date By
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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. ELR2017-00258
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10100 SW Washington Square Rd
Project Name: Red Robin
Job No.: N/A
Refund Method: ® Check#227693 in the amount of$67.20.
0 Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 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,
4 #
Dianna Howse
Building Division Services Supervisor
Enc.
i
1
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov