Permit Support Document \ CA0yll:
City of Tigard • CO N1UNITY D1:VELOPMENT DEPARTMENT
lill Request for Permit Action
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TIGARD 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439• www.ttgard-or.got )2/, '
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 cEIV
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPcrmirs@ p-o gov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City St41'�f/'`/R'�24 2OZO �^p
Check{Jl one CITY OF 1 i A i 0
REFUND OR Name: BUILDING DIVISIO
INVOICE TO: (Businfss or Individual) 17
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Mailing Address: -1- t 'c-,`, A) c, S-c. -,,„ c ')r--
City/State/Zip: bo c >e...R. s.. t' cfl (7 c6
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Phone No.: j 3 — 2 A..7 <(j- < <7 i 1
PLE TAKE ACTION FOR THE ITEM(S) CHECKED (.1):
CANCEL/VOID PERMIT APPLICATION.
Er REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: El..-C... 2oi ., c oci-)< Z,,
Site Address or Pai cel#: \ ' S 46 Zs ) .-- ,tx
Protect Name: v, >t j-- C 3
Subdivision Name:' Lot#:
EXPLANATION: 0\:Th \ )C_,,,. , C,c,,c\cs ,A,t Q
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Print Name:
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Refund Policy !
1. The city's Community Develomcnt Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroticously 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
i • 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.Q �^ t,
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FOR OFFICE USE ONLY
Route to Sys Adntin: I)a:c "0 By /,�, Rothe to Records: Date ... / /'2/ By /
Refund Processed: Date/'l .` BF,4�0' Invoice Processed: Date / By
Permit Canceled: Date,-y By /7 Parcel Tag Added: Date By
is\Building\Forms\RegPennitAttion 1205I&dot
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TIGARD
City of Tigard
December 22, 2020
Steele Electric
7741 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELC2019-00362
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12388 SW Scholls Ferry Rd
Project Name: McDonald's
Job No.: N/A
Refund Method: ® Check#237588 in the amount of$63.64.
❑ Credit card "return"receipt in the amount of$
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,
d�04/)z l
Dianna Ornelas
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
City of Tigard
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 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 Steele Electric DATE: 12/9/2020
TO:
7741 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 423745 Case #: ELC2019-00362
Date: 5/29/2019 Address/Parcel: 12388 SW Scholls Ferry Rd
Pay Method: CreditCard Project Name: McDonald's
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit Fee 220-0000-43103 $56.82
12%State Surcharge 100-0000-24001 6.82
TOTAL REFUND: $63.64
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff , �7 ,
If under$12,500 Division Manager 1J L. OVP
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: . ,/,/,> x.-/' By:
I:A Building\Refunds\RefundRequest.doc x 09/O1/2010
1111 II
CITY OF TIGARD RECEIPT
it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: 190422
Site Address: 12388 SW SCHOLLS FERRY RD ,i E- �
Receipt Number: 435827 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00362
$-63.64
Total: $-63.64
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237588 DHOWSE 08/13/2021 $-63.64
Payor: Steele Electric
Total Payments: $-63.64
Balance Due: $63.64
Page 1 of 1
CITY OF TIGARD RECEIPT
i' 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: 190422
Site Address: 12388 SW SCHOLLS FERRY RD n 4. (6 rAM-I
Receipt Number: 423745 - 05/29/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00362 Branch Circuits wo/Purchase Service or 220-0000-43103 $71.02
Feeder
ELC2019-00362 12%State Surcharge-Electrical 100-0000-24001 $8.52
Total: $79.54
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 290519E3C-861( PUBLICUSER109 05/29/2019 $79.54
Payor: Kandice Brown
Total Payments: $79.54
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
S 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TlC;AI:I)
Project Name: 190422
Site Address: 12388 SW SCHOLLS FERRY RD
Receipt Number: 423745 - 05/29/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00362 Branch Circuits wo/Purchase Service or 220-0000-43103 $71.02
Feeder
ELC2019-00362 12%State Surcharge-Electrical 100-0000-24001 $8.52
Total: $79.54
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 290519E3C-861( PUBLICUSER10982:05/29/2019 $79.54
Payor: DanSteele
Total Payments: $79.54
Balance Due: $0.00
I
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