Permit Support Document (2) p
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TIGARD
City of Tigard
November 8, 2019
Advanced Electric Signs Inc
Attn: Steve Slack
1550 Down River Dr
Woodland,WA 98674
Re: Permit No. ELC2019-00590
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9412 SW Washington Square Rd
Project Name: Lunch Box
Job No.: N/A
Refund Method: ® Check#233817 in the amount of$60.78.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 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 Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
i1111111 II
1 City of Tigard
T I G A R D 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: Advanced Electric Signs Inc DATE: 11/1/2019
1550 Down River Dr.
Woodland, WA 98674 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 425647 Case#: ELC2019-00590
Date: 9/5/2019 Address/Parcel: 9412 SW Washington Square
Rd
Pay Method: CreditCard Project Name: Lunch Box
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 Fees 220-0000-43103 $54.27
12%State Surchage 100-0000-24001 6.51
TOTAL REFUND: $60.78
APPROVALS: SIGNATU 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: p/7/4/ By: 494
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T I G.A R D
Project Name: Lunch Box
Site Address: 9412 SW WASHINGTON SQUARE RD K10
A AiA
Receipt Number: 436188 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00590 $-60.78
Total: $-60.78
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 233817 DHOWSE 09/03/2021 $-60.78
Payor: Advanced Electric Signs Inc
Total Payments: $-60.78
Balance Due: $60.78
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TEG1lR.
Project Name: Lunch Box
Site Address: 9412 SW WASHINGTON SQUARE RD K10
&-/C-/Arm"z.
Receipt Number: 425647 - 09/05/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2019-00590 Sign or Outline Lighting 220-0000-43103 $67.84
ELC2019-00590 12% State Surcharge-Electrical 100-0000-24001 $8.14
Total: $75.98
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5525473 PUBLICUSER311 09/05/2019 $75.98
Payor:
Total Payments: $75.98
Balance Due: $0.00
Page 1 of 1
•
Order Receipt 5525473
Subject:Order Receipt 5525473
From:PayGov<no-reply@paygov.us>
Date:9/5/2019, 10:32 AM
To:info@advancedelectricsign.com
iP,a yao v US
This email is a confirmation of your Online Payment for PERMIT CENTER
Cardholder Name:Susan Slack
Telephone::(360)225-6826
Credit Card Type :Visa
Last 4 digits:4XXX XXXX XXXX 8865
Confirmation Number:5525473
Card Auth Code:005796
Transaction ID: 1584049666
Agency Payment Amount:$75.98
Convenience Fee :$2.28
.. Total Amount Charged :$78.26 -""—"—
First Name:Steve
Last Name:Slack
Your payment to PERMIT CENTER has been processed by PayGov, LLC.
NOTICE.Two charges will appear on your credit card or bank statement.
One is for the Tax,Fine,or Fee owed to the government agency and will reflect the name of the agency.
The other is for the convenience fee assessed by PayGOV.US and will reflect"Convenience Fee"on your statement.
For questions or concerns contact PayGOV.US at 1-866-480-8552.Transaction disputes will result in a$40 charge to the
cardholder.
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