ADJ2017-00018 VOIDED
ADJ2017 - 00018
CHICK- FIL-A
q
TIGARD
City of Tigard
July 16, 2018
Chick-fil-A
Attn: Brenda Porrazzol
15635 Alton Parkway, Suite 350
Irvine, CA 92618
Re: Permit No. ADJ2017-00018
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10935 SW 68th Pkwy
Project Name: Chick-fil-A
Job No.:
Refund Method: ® Check #228914 in the amount of$791.00.
❑ Credit card "return" receipt in the amount of$
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): Adjustment no longer needed;refund 100% of application fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
eoo)��
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
41
City of Tigard
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 PermitAction 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: Chick-fil-A DATE: 6/22/2018
15635 Alton Parkway, Suite 350
Irvine, CA 92618 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION: 5A4--Le/7 -ot)V D G
Receipt#: 413205 Case#: AEBJ26t7-''66MS—
Date: 10/5/2017 Address/Parcel: 10935 SW 68thPkwy
Pay Method: Check Project Name: Chick-fil-A
EXPLANATION: Adjustment no longer needed;refund 100% of application fee.
REFUND INFORMATIONS
Fee'Deseriptiou From Receipfi' , . mi nue Account No. Refund
Example:. Buildin 'Permit Fee Example:` 2300000-43104 $Amount
Access/Egress Standard Adjustment 100-0000-43116 $791.00
TOTAL REFUND: $791.00
APPROVALS: SIGNA /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
FOR TIDEMARKSYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: B
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
ki 0 1 D
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
g
Request for Permit Action
(a/Z
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-orgov
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 F-1Contractor [ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Chime T _A &-infieh Po r razu �
Mailing Address: A[Vion Pa n(.wa!4 J\.ult
City/State/Zip: I 2-y lho CA� q�lb
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
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 #: & W W VI — 000 k Fj
Site Address or Parcel #: Joqw SV,4 AQ y
Project Name: Ck ICS- V-1
Subdivision Name: Lot #:
EXPLANATION: ND p I I (gym n 4 cj 1.
Signature: Date: 1517's.11(6
Print Name:
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.
FOR OFFICE- USE' ONLY
Route to Sys Admin: Date By oute to Records: Date
Refund Processed: DateZ /J- B Invoice Processed: Date B
Permit Canceled: Date / B Parcel Tag Added: Date B
I:\Building\forms\Regl'errrritkction_0 2314.8oc