Permit Support Document (63) From:Rayborns Plumming INC 503+691+2328 02/07/2019 10:16 #902 P.001/002
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT FEB 1 1 2019
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2 Request for Permit Action c l! I : rIGARD
TIGARD 13125 SAX'Hall Blvd. •Tigard,Oregon 97223• 503-718-2439 • www,tigatd_M/U c DIVISION
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPernuts@tigard-or.gov
FROM: ❑ Owner ❑ Applicant g Contractor ❑ City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Rte yba r►1. 5 17),vu 1
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Mailing Address: p O 3o1( 6
City/State/zip: c�t w�" (�(,r3 017 O
Phone No.: S 03 6a 2 t
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
/e(CA.NCEL/VOID PERMIT APPLICATION.
ixr REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PL-,,&, 20 1 (1 - c o o L I L-1
Site Address or Parcel#: ) '3cS \„j j N PR ,
Project Name:
Subdivision Name: Lot#:
EXPLANATION: was u-bJP
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Signature: ,� e,,! ../, % Date: 2 '7-7Print Name: �lo //� -' A--
Refund Policy
1. The 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 4
3 Please allow 3-4 weeks for processing refund requests. 7�• S(� — .d � try
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FOR OFFICE USE ONLY
Route to Sys Admin: Date �, /1 4 By .71 Route to Records: Date 1/.. / By .4°1.-
Refund
• 1.Refund Processed: Date3 / By Invoice Processed: Date By
Permit Canceled: Date 7/ 4' /y By - Parcel Tag Added: Date Bt'
1:\Building\Forms\ResPermit Action,,42051 .doe
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TIGARD
City of Tigard
April 4, 2019
Rayborn's Plumbing
PO Box 69
Tualatin, OR 97062
Re: Permit No. PLM2019-00044
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13581 SW Liden Dr
Project Name: Sheppard
Job No.: N/A
Refund Method: ® Check#231717 in the amount of$64.96.
0 Credit card "return" receipt in the amount of$ .
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as they were able to make repairs and new water
service was not required. Refund 80% of permit fees.
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
II II
City of Tigard
r c A R a 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 Permit Action 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: Rayborn's Plumbing DATE: 3/28/2019
PO Box 69
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 421351 Case#: PLM2019-00044
Date: 1/31/2019 Address/Parcel: 13581 SW Liden Dr
Pay Method: CreditCard Project Name: Sheppard
EXPLANATION: Per applicant's request as was able to make repairs,no new water service required.
Refund 80%of permit fees.
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Plumbin. Permit 230-0000-43101 $58.00
12%State Surchar•e 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNAT�jR DATE:
If under$5,000 Professional Staff ��///
If under$12,500 Division Manager
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
Case Refund Processed: Date: I G//$//2 By: -.07 r
I:\Building\Refunds\RefundRequest.doc x 09/01/2010