Permit Support Document (66) 2018/08J21 1311 :55 2 /3I-RE(.14 I y
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City of Tigard • COMMUNITY DEVELOPME T DEPARTMENT -,
712 Request Permit ActionIP °F TIGARD !.
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.h I iA R D 13125 SW Ball Blvd. •Tigard, Oregon 97223 • 503.718.2439•www.tigard-or.gov
•
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: (Busyness or Individual)
MailingAddress: 7989 SW Cirrus Dr 1
City/State/Zip: Beaverton, OR 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERIvMIT APPLICATION.
I:1 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/R:PLA.CE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELR2018-00051
Site Address or Parcel#: 7150 SW Hampton St Ste 224
Project Name: EBS Associates
Subdivision Name: Lot#:
EXPLANATION: Customer cancelled the install
Signature: Date: 8/21/18
Lori McMurphy
Print Name: 75.- � — f 0 ,o-ri " /-5:41v
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Refund Police ,.
I. The Director or BuildingOfficial may
•authorize the refund of: P9,•G 6.7 ?-( 76,GFO
a) any fee which was erroneously paid or collected.
b) not more than t0%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) nol more than 80°.Si of the land use application fee for issued permits.
(I) not more than Eiif,li of the building plan review lee when an application is canceled before any plan review effort has been expended.
e) not more than KM,of the building permit Lee for issued permits prior to any inspection requests.
2. Refunds will he returned to the original Payer in the same method in which payment was received. Please.allow 2-4 weeks for processing refund.;.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rtc to Bldg Admin: Date if 12_ ,9 B. ,
Refund Processed: Dale`?/41 /f--- _ ] Invoice Processed: Date By
Permit Canceled: Date 9 /�,,j,1 By Parcel Tag Added: Date By
Receipt# Date Method _ Amount$
I:\Building`•,Forms\RcgPermitAction.doc Rev 05/25/2012
TIGARD
City of Tigard
September 17, 2018
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2018-00051
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7150 SW Hampton St, Ste 224
Project Name: EBS Associates
Job No.: N/A
Refund Method: ® Check#229720 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
11,1
City of Tigard
T I G 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#: 416543 Case#: ELR2018-00051
Date: 4/5/2018 Address/Parcel: 7150 SW Hampton St,#224
Pay Method: CreditCard Project Name: EBS Associates
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
-:lr ,«'
Electrical Permit 220-0000-43103 $60.00
12%State Surchar.e 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGN RES/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
,a c ORt v y..:.: Sx _ ( tI . E'" NL ,I "
Case Refund Processed: I Date: I /2.// By: 4—
I:\Building\Refunds\RefundRequest.doc x 09/01/2010