Permit Support Document 1111 a
TIGARD
City of Tigard
January 28, 2020
ADT LLC
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2019-00198
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 7150 SW Hampton St,226
Project Name: Mustard Financial Services Inc.
Job No.: N/A
Refund Method: ® Check#234429 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 permit was obtained for the wrong address.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,d
Dianna Howse
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
im
I City of Tigard
r c A RD 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: 1/17/2020
7989 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 426500 Case #: ELR2019-00198
Date: 10/18/2019 Address/Parcel: 7150 SW Hampton St,226
Pay Method: CreditCard Project Name: Mustard Financial Services Inc
EXPLANATION: Per applicant's request as obtained permit for the wrong address. 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
0
12/o State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNA ES/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: gtoy - By: 4 �r
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
q
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
11111
503.639.4171
TIGAR.D
Project Name: Mustard Financial Service Inc
Site Address: 7150 SW HAMPTON ST 226
Receipt Number: 436202 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00198 $-67.20
Total: $-67.20
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 234429 DHOWSE 09/03/2021 $-67.20
Payor: ADT LLC
Total Payments: $-67.20
Balance Due: $67.20
Page 1 of 1
CITY OF TIGARD RECEIPT
111111 I 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGA D
Project Name: Mustard Financial Service Inc
Site Address: 7150 SW HAMPTON ST 226
®/Z /f✓,g�
Receipt Number: 426500 - 10/18/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00198 Restricted Energy Permit 220-0000-43103 PC lc $75.00 ‘—
ELR2019-00198 12%State Surcharge-Electrical 100-0000-24001 rp $9.00 t--
Total: $84.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5674530 PUBLICUSER10736:10/18/2019 $84.00
Payor:Imcmurphy
Total Payments: $84.00
Balance Due: $0.00
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