Permit Support Document (2) N
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City of Tigard
August 9, 2019
GasPro Inc
4120 SE International Way, Ste A109
Milwaukie, OR 97222
Re: Permit No. MEC2019-00170
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13195 SW Ash Dr
Project Name: Koch
Job No.: N/A
Refund Method: El Check#232918 in the amount of$100.80.
❑ Credit card "return"receipt in the amount of$
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 obtained online (see
MEC2019-00194). Refund 100% 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
IN
i C " 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: GasPro Inc. DATE: 8/2/2019
4120 SE International Way, Ste A109
Milwaukie, OR 97222 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 422179 Case#: MEC2019-00170
Date: 3/21/2019 Address/Parcel: 13195 SW Ash Dr
Pay Method: CreditCard Project Name: Koch
EXPLANATION: Per applicant's request as duplicate permit was obtained online (see MEC2019-00194).
Refund 100%per permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No, Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Mechanical Permit 230-0000-43102 $90.00
12%State Surcharge 100-0000-24001 10.80
TOTAL REFUND: $100.80
APPROVALS: SIGNATURES DAT :
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: //,,„)7/) ( By: , ,,�,�' �)
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
111ii
1 CITY OF TIGARD RECEIPT
iI , 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Koch
Site Address: 13195 SW ASH DR
Receipt Number: 436084 - 08/27/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
M E C2019-00170 $-100.80
Total: $-100.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 232918 DHOWSE 08/27/2021 $-100.80
Payor: GasPro Inc
Total Payments: $-100.80
Balance Due: $100.80
Page 1 of 1
CITY OF TIGARD RECEIPT
i ! 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
IIC;;t,II.D
Project Name: Koch
Site Address: 13195 SW ASH DR c/ ( `,A'7_
Receipt Number: 422179 - 03/21/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
MEC2019-00170 Gas Fireplace 230-0000-43102 $33.39
MEC2019-00170 12%State Surcharge-Mechanical 100-0000-24001 $10.80
MEC2019-00170 Minimum Fee Adjustment-Mechanical 230-0000-43102 $56.61
Total: $100.80
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 210319E3D-E50I PUBLICUSER107 03/21/2019 $100.80
Payor: JoAnn E Phillips
Total Payments: $100.80
Balance Due: $0.00
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