Permit Support Document (64) kAttiZtrti
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT % x
_: Request for NOV 8 2018
q o Permit Action
TIGARD 13125 SAY' Hall Blvd. • 'Tigard,Oregon 97223 . 503-718-2439 • wuw.tiy;:trcl f("m10l ill,-,,,
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TO: CITY OF TIGARD
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Building Division
13125 S\V Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov/����
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
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REFUND OR Name:
INVOICE TO: (Itusmcss or Individual) R 0 Ti-I HEAT-IN 3 coo L iN Ca
Mailing Address: PO BOK 126 •
City/State/Zip: CAN 6Y, OR 41013
Phone No.: 503 - 2b 6 -31.178
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 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 #: SLC 2-ol$ - 00112-
Site
D0`l12-
Site Address or Parcel #: 1'272$' SW W ILLS , PL
Project Name: SAL, NA 11-1028
Subdivision Name: BELL W00 p Lot#: 2
EXPLANATION: C USTO MER CAN CE LL Wop.
Signature: Date: 11/$`le
Print Name: ROBERT sIoIce
Refund Policy
I, 'lite city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Nm more than 8U" of the application or plan review fcc when an application is withdrawn or canceled before review effort
has been expended.
• Not more than AIM.w,of the application or permit fee for issued permits prior to any inspection requests.
VI refunds will be returned io the original payer in the form of a check via US postal service.
l'It,,tsc allow 3-4 weeks for processing refund requests. / 3 &
7i, .5,2 / 25'
FOR OFFICE USE ONLY
Route to Sys Admin: Date _ By Route to Records: Date z- /F By < i�
Refund Processed: Date////CA B Invoice Processed: Date By.
Permit Canceled: Date j//jb Br f'" Parcel Tag Added: Date B
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TIGARD
City of Tigard
November 29, 2018
Roth Heating&Cooling
PO Box 1265
Canby, OR 97013
Re: Permit No. ELC2018-00712
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12725 SW Wills P1
Project Name: Saldana
Job No.: N/A
Refund Method: ® Check#230485 in the amount of$56.98.
❑ Credit card"return"receipt in the amount of$ .
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,
<*(74W—,- --
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
City of Tigard
r r A RD 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: Roth Heating&Cooling DATE: 11/16/2018
PO Box 1265
Canby, OR 97013 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 420140 Case#: ELC2018-00712
Date: 10/26/2018 Address/Parcel: 12725 SW Wills P1
Pay Method: CreditCard Project Name: Saldana
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
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Electrical Permit Fee 220-0000-43103 $50.88
12%State Surchar.e 100-0000-24001 6.10
TOTAL REFUND: $56.98
APPROVALS: SIGN , /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: I Date:I 17/z//7 By: tri►"
I:\Building\Refunds\RefunjRequest.doc x 09/01/2010