Permit Support Document (63) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
= Request for Permit Action
TIGARD 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 11 Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Lin R Rogers Electrical Contractors Inc
Mailing Address: 2050 Marconi Dr. Ste 100
City/State/Zip: Alpharetta, GA 30005
Phone No.: 770-772-3429
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICATION.
0 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#: ELC2018-00588
Site Address or Parcel#: 14800 SW Sequoia Parkway.Tigard, OR 97224
Project Name: Home Depot 4002
Subdivision Name: Lot#:
EXPLANATION: No work has been done and project has been cancelled
Signature: ;ya Date: 10/11/18
di
Print Name: LirxR Rogers
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
9 5/ V 3
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date Cie /2
Refund Processed: Date /VV B Invoice Processed: Date By
Permit Canceled: Date //7/ B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_o 2314 oc
TIGARD
City of Tigard
November 29,2018
Lin R Rogers Electrical Contractors Inc.
2050 Marconi Dr., Suite 100
Alpharetta, GA 30005
Re: Permit No. ET.C2018-00588
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14800 SW Sequoia Pkwy
Project Name: Home Depot
Job No.: N/A
Refund Method: ® Check#230452 in the amount of$50.33.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 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,
dam._
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
1111
I . City of Tigard
i n,t 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: Lin R Rogers Electrical Contractors DATE: 11/16/2018
Inc
2050 Marconi Dr., Suite 100
Alpharetta, GA 30005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 419292 Case#: ELC2018-00588
Date: 9/5/2018 Address/Parcel: 14800 SW Sequoia Pkwy
Pay Method: CreditCard Project Name: Home Depot
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
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Electrical Permit Fee 220-0000-43103 $44.94
12%State Surchar.e 100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SIGN / P ATE:
If under$5,000 Professional Staff t(4 j p / -
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: I /7/ifBy: .
I:\Building\Refunds\RefundRequest.doc x 09/01/2010