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Permit Support Document (56) 0 ii: 3Av,, FEB t 9 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 4. i V Request for Permit Action I ,,,A p.iD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.gov 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 Check(V)one [4 REFUND OR Name: INVOICE TO: (Business or Individual) r:b-c- I / C ,, Mailing Address: --i 1( C S w (.C r rLA:s 1�)t- r 1`• City/State/Zip: (XtJ-e 4 Ai-r,. C92 q'l o Phone No.: -f' t4(A i' .Lk i, 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). Permit#: 'eL$-, aO(55 - 06 2-, 1 Site Address or Parcel#: ( 0 ( t 0 ' &. .) n 1 r(\ - t.., Au.0 5 Bt I , Project Name: e a.(( I LArITYN Subdivision Name: 1 Kp I ..s i st‘-e55 Oni,tc \t (ot#: EXPLANATION: C LAS-�fm124- 0orn C.4.„,k, 2 c cNr.....c klak. Signature: - qoti 4 h... Date: ?�,\`9 Print Name: 1-41-4- % 1.114-INN t r 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 3. Please allow 3-4 weeks for processing refund requests. -75 c-T - 400,re FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date dj 5 /J By i''"' Refund Processed: Date 3 c , Byte/D/1 Invoice Processed: Date By Permit Canceled: Date ; L19 B Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_I 0578. oc . TIGARD City of Tigard April 4, 2019 ADT LLC 7989 SW Cirrus Dr Beaverton, OR 97008 Re: Permit No. ELR2018-00231 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 10110 SW Nimbus Ave.,B11 Project Name: Claire Luton Job No.: N/A Refund Method: ® Check#231665 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, 055/61- 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 114 " City of Tigard Accela Refund Request IIGARD q 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: ADT LLC DATE: 3/29/2019 7989 SW Cirrus Dr Beaverton, OR 97008 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 420771 Case#: ELR2018-00231 Date: 12/13/2018 Address/Parcel: 10110 SW Nimbus Ave,B11 Pay Method: CreditCard Project Name: Claire Luton EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees. c � e4a6a �€ a€ s410x € € fie €eg#eex Restricted Ener. Permit 220-0000-43103 $60.00 12%State Surchar.e 100-0000-24001 7.20 TOTAL REFUND: $67.20 APPROVALS: SIGNAT ES 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 ACOOKLOSITOTAD Case Refund Processed: Date: 9./S /j By: I I:\Building\Refunds\RefundRequest.doc x 09/01/2010