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Permit Support Document (69) RECAVPD /1O' //f OCT 1 0 2018 City of Tigard • COMMUNITY DEVELOPMENT DEPARTM ' . ;` '(� [� r iEi l i'VI :I 1N N . r Request for Permit Action 116 A R l) 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: D Owner 0 Applicant ❑ Contractor ❑ City Staff Check(1)one REFUND OR Name: `;� INVOICE TO: (Business or Individual) r Y 0 ) g LH RD t,W/ 14. Mailing Address: ?.b . v1 x 1 'g� City/State/Zip: }LLA S, O g 6'17'33 Phone No.: _5-6,3 - 76-O -626 7 PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (✓): ANCEL/VOID PERMIT APPLICATION. ..2 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). • Permit#: EL-X 2Oi?e:-.)o ) 75-- Site 5Site Address or Parcel#: 471:,4i5 4)34...._:_41:1/3-1,? 37'L lei-Le' • Project Name: C LeE7 b1J o r TL- L3 . Subdivision Name: Lot#: EXPLANATION: in)E-- NE-6,2&---y...) AO Ezez-nzi< l_ jP2-?-1 1r • Fbir— A 012046 - l -err T-cS , LvYaY1L, 2e�r1-r*1T. F,44)/ LWt)JJE_ �z€- -SE' --z /e-,—. e 6 Signature: _ Date: f 6//d i'Print Name: 27 61/1A/ ©Lir A/A/s ' i. Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund ofi • 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 fcc 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, Ct' - t,'e),iv "s• • 0 • 6(•=. et 7 ,2-e it, rid Route to Sys Admin: Date By Route to Records: Date ? 2- /`j' By Refund Processed: Date/ /�, /1 By Invoice Processed: Date By Permit Canceled: Date // /,j B, Parcel Tag Added: Date By •I I:\Building\Forms\RegPermitAction_0 2314. oft c i N TIGARD City of Tigard November 29,2018 Pro Tech Power Attn: Devin Oltmanns PO Box 988 Dallas, OR 97338 Re: Permit No. ELR2018-00175 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 9645 SW ShadyPl Project Name: Cleeton Job No.: N/A Refund Method: ® Check#230481 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 work required an electrical permit (ELC2018- 00666). Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, 452fZ,-ze„---t-e 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 lig li I City of Tigard T 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: Pro Tech Power DATE: 11/16/2018 PO Box 988 Dallas, OR 97338 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 419843 Case#: ELR2018-00175 Date: 10/9/2018 Address/Parcel: 9645 SW Shady P1 Pay Method: CreditCard Project Name: Cleeton EXPLANATION: Per applicant's request as work required an electrical permit(see ELC2018-00666). Refund 80%of permit fees. FAIRE"a0 �.° .. Aki� 7 : � �� "'T� 'J� '''':17:77:' : , , ,� m ` � E w ,, fir ‘ y a .v � � J riPti a °� a ea ;:' -'1. '.i-61: :...e. ,--'1,:'2,.la ° i;':,' i a k�C A.41 Electrical Permit Fee 220-0000-43103 $60.00 12%State Surchar:e 100-0000-24001 7.20 TOTAL REFUND: $67.20 APPROVALS: SIGNMU S DATE: If under$5,000 Professional Staff • -V- 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 Case Refund Processed: Date: Vi,Z/7 By: 444 I:\Building\Refunds\RefundRequest.doc x 09/01/2010