Permit Support Document II q
E
TIGARD
City of Tigard
April 3, 2020
Cochran Inc.
7550 SW Tech Center Dr., Ste 200
Tigard, OR 97223
Re: Permit No. ELC2019-00869
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7105 SW Hampton St
Project Name: Kaiser
Job No.: N/A
Refund Method: // Check#235110 in the amount of$203.97.
❑ Credit card "return"receipt in the amount of$ .
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 this was a duplicate permit (see ELR2019-
00203). Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
.d.2; e:/i4se. ,/, ....,L)
Dianna Ornelas
Building Division Services Supervisor
Enc.
1
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
III .1
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 TO: Cochran Inc DATE: 3/20/2020
7550 SW Tech Center Dr, Ste 220
Tigard, OR 97223 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 427429 Case #: ELC2019-00869
Date: 12/18/2019 Address/Parcel: 7105 SW Hampton St
Pay Method: CreditCard Project Name: Kaiser
EXPLANATION: Per applicant's request as they obtained a duplicate permit in error. 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 220-0000-43103 $182.11
12%State Surcharge 100-0000-24001 21.86
TOTAL REFUND: $203.97
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff 2�C
If under$12,500 Division Manager
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: By: I ,,K-(,•�/'�
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
q
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Kaiser TGD OHAP ,Site Address: 7105 SW HAMPTON ST 4/7 r
.c A d�
Receipt Number: 436225 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00869 $-203.97
Total: $-203.97
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 235110 DHOWSE 09/03/2021 $-203.97
Payor: Cochran Inc.
Total Payments: $-203.97
Balance Due: $203.97
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TR API)
Project Name: Kaiser TGD OHAP
Site Address: 7105 SW HAMPTON ST
Receipt Number: 427429 - 12/18/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00869 Branch Circuits wo/Purchase Service or 220-0000-43103 $152.64
Feeder
ELC2019-00869 Signal circuit or Limited Energy Panel 220-0000-43103 $75.00
ELC2019-00869 12%State Surcharge-Electrical 100-0000-24001 $27.32
Total: $254.96
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5867804 PUBLICUSER107 12/18/2019 $254.96
Payor:
Total Payments: $254.96
Balance Due: $0.00
Page 1 of 1