Permit Support Document q
TIGARD
City of Tigard
April 3, 2020
ADT LLC
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2019-00199
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7150 SW Dartmouth St
Project Name: Pediatric Assoc of NW
Job No.: N/A
Refund Method: ® Check#235088 in the amount of$67.20.
❑ Credit card "return"receipt in the amount of$
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,
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
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: ADT LLC DATE: 3/20/2020
7989 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 426536 Case#: ELR2019-00199
Date: 10/21/2019 Address/Parcel: 7150 SW Dartmouth St
Pay Method: CreditCard Project Name: Pediatric Assoc of NW
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 220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNA RES/DATE:
If under$5,000 Professional Staff �\`? �
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: C j3 `7,-/ By: c�/
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
114 CITY OF TIGARD RECEIPT
0. 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Pediatric Assoc of the NW
Site Address: 7150 SW DARTMOUTH ST
Receipt Number: 436221 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00199 $-67.20
Total: $-67.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 235088 DHOWSE 09/03/2021 $-67.20
Payor: ADT LLC
Total Payments: $-67.20
Balance Due: $67.20
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ii
CITY OF TIGARD RECEIPT
Ihil
■ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Pediatric Assoc of the NW
Site Address: 7150 SW DARTMOUTH ST
Receipt Number: 426536 - 10/21/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00199 Restricted Energy Permit 220-0000-43103 $75.00
ELR2019-00199 12% State Surcharge-Electrical 100-0000-24001 $9.00
Total: $84.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5682323 PUBLICUSER10736t10/21/2019 $84.00
Payor:Imcmurphy
Total Payments: $84.00
Balance Due: $0.00
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