Report TIGARD
City of Tigard
May 2, 2017
Polygon WLH,LLC
Attn: Angela Grajewski
109 East 13th St
Vancouver,WA 98660
Re: Permit No. MST2016-005 8/SWR2016-00439
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 17452 SW Shadow Trail St
Project Name: River Terrace Northwest,Lot 119
Job No.: N/A
Refund Method: ® Check#224417 in the amount of$8,248.48.
❑ Credit card"return"receipt in the amount of$
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 house plans were changed. Refund 100%of
permit fees and 80% of plan review fees. Transfer all SDC fees to new permits MST2017-
00124 and SWR2017-00115..
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
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
• 503.639.4171
TIGARD
Receipt Number: 409834 - 04/05/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2017-00115 Sewer Connection Fee 500-0000-25500 $5,300.00
SWR2017-00115 Sewer Inspection-Residential 230-0000-43118 $35.00
Total: $5,335.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Fund Transfer DHOWSE 04/05/2017 $5,335.00
Payer:
Total Payments: $5,335.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD R1P
RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
L?A/C//✓f!-L
Receipt Number: 408436 - 01/23/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2016-00439 Sewer Connection Fee 500-0000-25500 $5,300.00
SWR2016-00439 Sewer Inspection-Residential 230-0000-43118 $35.00
Total: $5,335.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 71333 DHOWSE 01/23/2017 $5,335.00
Payor: Polygon WLH, LLC
Total Payments: $5,335.00
Balance Due: $0.00
Page 1 of 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
V 0 I 461
11 -I Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.gov
y/10 7
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 ❑ Contractor El City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 0 Ls/ Coo t3 µ LG c.
Mailing Address: I.09. EAST 13"'" 5-rag£.T
City/State/Zip: J A,J Cvl t J t l,J!} q 1'6
Phone No.: (120- (ct ej- 7700
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® 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 't). ---
Permit#: P-I ST 07o I L- DO 5 a ( 1-AD R bta 1 (,-cot 39
Site Address or Parcel#: 1 7 45 2- tw 14.14
Project Name:
Subdivision Name: Lot#:
S a//Z2o/7-00/Lc EXPLANATION:
1�E $Htrta Lcnli je 7- co -q , Ag,c,, J'n
loot ore Qe2F/, 6EE5 * e_ Lee. 4er.4/AJ 4wARnl 2.*de
Signature: V ek _ Date: rs 4/7
Print Name: I t6/3,EL. PrD/i-,�tgl,,�
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 Admire Date By Route to Records: Date o 3 By if -
Refund Processed: Date V/p//7 By Invoice Processed: Date By
Permit Canceled: Date y/y//7 By `" Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_6923 4.doc