Permit Support Document 2018/08/24 10:52:46 2 /3
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City of Tigard •• COM1v1UNITY DEVEL PM NT DEPARTMENT AUG 27 2O1
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•± l 2, ' Request uest Permit Action7,
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TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • www ' ;�v` N
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: ADT LLC
INVOICE TO: (Business or Individual)
Mailing Address: 7989 SW Citrus Dr
City/State/Zip: Beaverton,OR 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICJVIION.
V REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELR2018-00046
Site Address or Parcel#: 15353 SW Sequoia Pkwy#100
Project Name: Inspired Results
Subdivision Name: Lot#:
EXPLANATION: Customer cancelled install
Signature: __..._.--. f: _ L ` s1�r('1 :>,,�.1 Date: �J { 1
Lori McMu>phy p y
Print Name: 7S Cre — 6, Cl , C /S= ed
r Cr t) — 2, 3-d - /. ce0
Refund Policy /
1. The Director or Building Official may authorize the refund of �i 1 Cd 1(t 7r (/
'
a) any fee which was erroneously paid or collected. v ' (J
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80°'a of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) riot more than 80°'0 of the building permit fee fox issued permits prior to any inspection rtxluests.
2. Refunds will be returned In the original Payer in the same method in which payment was received, Please allow 2-4 weeks fur processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: ' Date By Rte to Bldg Admin: Date %/ /Z if By ~
Refund Processed: Date/0 7/ B, Invoice Processed: Date By
Permit Canceled: Date �C)/i'CF—B r Parcel Tag Added: Date By
Receipt# Date /// Method Amount I
l\Building\l,orms\Regl'ernvtAction.doc Rev 05/25/2012
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TIGARD
City of Tigard
September 17, 2018
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2018-00046
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15353 SW Sequoia Pkwy#100
Project Name: Inspired Results
Job No.: N/A
Refund Method: ® Check#229721 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 customer cancelled the job. 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
p City Tigard
Ti and
r,c A R D 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: ADT LLC DATE: 9/10/2018
7989 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 416392 Case#: ELR2018-00046
Date: 3/29/2018 Address/Parcel: 15353 SW Sequoia Pkwy#100
Pay Method: CreditCard Project Name: Inspired Results
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
ri-OPI
�, efi s,;i s Q L :e 7;7,..v53),111sir
Electrical Permit 220-0000-43103 $60.00
12%State Surchar.e 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIG TURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
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Case Refund Processed: Date: V/i//9 By:,4 r
I:\Building\Refunds\RefundRequest.doc x 09/01/2010