Permit Support Document /
City of Tigard •COMMUNITY OEM OPMENT DEPARTMENT volD
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Request for Permit Action
13125 SW Hall Illivd.•Tigard,Oregon 97223•503-718-2439•wirar.titratd-ot,gcra /z/177d -(ad
RECEIVED
TO: crry OF TIGARD
Building Division MAR 2 4 2020
13125 SW Hail Blvd,rigitd,OR 97223
Phone: 503-718-2439 Fay 503-598-1960 Tiganfiluidaneernsib&Imikw4Ilw CITY OF reGARD
FROM 0 OWTBIS 6
0 Appliaint 0 contractor 0 city staffBUILDING DIVISION
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REFUND OR Nan=
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Mailing Address: '.k.g.70 6 E r2s-o- P . 4.103
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Phone No.: go3 -)co
PLEASE TARE ACTION FOR THE ITEM(S)CHECKED(,):
gCANCEL/VOID PERMIT APPLICATION.
REFUND PRUITT FEES(attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE(mach case lie scheduk and provide el:planation below).
Permit#: tkao /1-00'70c1
Site Address or Parcel#: 9 711 s v.., UU i'..11 S.e ri pkict
Project Name: r.itviep,\ CD LA,r-f
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TIGARD
City of Tigard
December 22, 2020
Ross Electric Inc.
2870 SE 75th Ave. #203
Hillsboro, OR 97123
Re: Permit No. ELC2019-00709
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9794 SW Windswept P1
Project Name: Canyon Ct
Job No.: N/A
Refund Method: ® Check#237586 in the amount of$53.19.
❑ Credit card"return"receipt in the amount of$
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,
G //
6/)-12.&s--)
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
City of Tigard
T A 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 forPermitAction 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 Ross Electric Inc. DATE: 12/9/2020
TO:
2870 SE 75th Ave. #203
Hillsboro,OR 97123 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 426498 Case#: ELC2019-00709
Date: 10/18/2019 Address/Parcel: 9794 SW Windswept P1
Pay Method: CreditCard Project Name: Canyon Ct
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
REF fiNF MATION" ``` , a l '�`'tV 3 =N e
�"' 'A ��� d� i i ; x � 4 N Ny44 ptN?� I *N..
Fee De riptio �r c �N ° Revue ��_ e
D t " zN = v ° i °�a "v f ` 6 '"7
�R� ti o � i��� �a �, tr�$a� � a S)a�g tip
�� `�^+y� p „� .. e�
:1 xam le lae J'J:.S.ee +.. a+m.ul�'Yui�91£�NNr Yp''�3' �i �'{�i1 '� "� r r ..;
Electrical Permit Fee 220-0000-43103 $47.49
12%State Surcharge 100-0000-24001 5.70
TOTAL REFUND: $53.19
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager D. L. Orneicus
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
Case Refund Processed: Date: `/ 'Z/ By: I ..70
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
G 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Canyon Ct.
Site Address: 9794 SW WINDSWEPT PL
AILS
Receipt Number: 435826 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00709 $-53.19
Total: $-53.19
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Cash 237586 DHOWSE 08/13/2021 $-53.19
Payor: Ross Electric Inc
Total Payments: $-53.19
Balance Due: $53.19
Page 1 of 1
1*
CITY OF TIGARD RECEIPT
.11111
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Canyon Ct.
Site Address: 9794 SW WINDSWEPT PL n /&rf1
Receipt Number: 426498 - 10/18/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00709 Temp Services or Feeders-200 amps 220-0000-43103 $59.36
or less
ELC2019-00709 12% State Surcharge-Electrical 100-0000-24001 $7.12
Total: $66.48
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5672773 PUBLICUSER112 10/18/2019 $66.48
Payor:
Total Payments: $66.48
Balance Due: $0.00
Page 1 of 1
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C 1TY OF TIGARD RECEIPT
,31/55vvmmilh4, rapt OR 97223
503 639 4171
Proem*Ream: Carryon Ct.
$ae Mee: 9794 SW WINDSWEPT PL
ReceiptNumbar: 426488 - 101117019
CAW . BRAISMEDRE SBNEMARLRWIRE ___
ELC2019-00709 Two Serapes or Feeders-200 amps 220-0300-431 03 $66.36
or law
ELC2019-00709 1 ra Wee Surcharge-Electrical 100-0000-24001 V.12
Tom- $IS.45
EAXIIIEUILESS OMEGA I MEMUNISK AMUR RfiRIERD RECEIPT DATE RECEIPT ANT
Credit Card 5672773 PuBLICUSERi I 25911 Wein 1 9 666 46
Payor Roiaelsaric 1
Tete'Paymeate: WAS
Selena Owe: 10 00
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