Permit Support Document 111,
•
TIGARD
City of Tigard
August 9, 2019
ADT LLC
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2019-00074
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12297 SW Main St
Project Name: The Chime Cellular
Job No.: N/A
Refund Method: ® Check#232895 in the amount of$134.40.
❑ Credit card"return"receipt in the amount of$
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 customer cancelled job. 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
1111 " 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: 8/2/2019
7989 SW Cirrus Dr
Beaverton, OR 97008 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 422979 Case#: ELR2019-00074
Date: 4/22/2019 Address/Parcel: 12297 SW Main St
Pay Method: CreditCard Project Name: The Chime Cellular
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
RttrOND INFORMATI'bN:
Fee Description From Receipt Revenue Account No." Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount ,°
Restricted Energy Permit 220-0000-43103 $120.00
12%State Surcharge 100-0000-24001 14.40
TOTAL REFUND: $134.40
APPROVALS: SIGNATURES DATE:
If under$5,000 Professional Staff \/.lJ�l
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
Case Refund Processed: Date: d-2 }/ By: 4,67t
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
xe„,.,n a:.xea,,.r. ,•,•,•,,: ,,. ... ,•; •••:•,a ,,..rz:. ixaxia>is: aux,..,:x iu m.
11
CITY OF TIGARD RECEIPT
1111ll • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: The Chime Cellular 402916193 --�
Site Address: 12297 SW MAIN ST
Receipt Number: 436086 - 08/27/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00074 $-134.40
Total: $-134.40
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 232895 DHOWSE 08/27/2021 $-134.40
Payor: ADT LLC
Total Payments: $-134.40
Balance Due: $134.40
Paae 1 of 1
CITY OF TIGARD RECEIPT
Ilij, 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TI6AR.l.)
Project Name: The Chime Cellular 402916193
Site Address: 12297 SW MAIN ST
d,2/
Receipt Number: 422979 - 04/22/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00074 Restricted Energy Permit 220-0000-43103 $150.00
ELR2019-00074 12%State Surcharge-Electrical 100-0000-24001 $18.00
Total: $168.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 220419E3E-3F4i PUBLICUSER107 04/22/2019 $168.00
Payor: Lori McMurphy
Total Payments: $168.00
Balance Due: $0.00
Page 1 of 1
RECEIVED
JUN 13 2019
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT CITY OF TIGARD
4 BUILDING DIVISION
Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD V
0
Building Division `y
13125 SW Hall Blvd.,Tigard,OR 97223 /
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Pc Contractor C City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: -7 l�r-t�_ C C 'd
City/State/Zip: ►✓)J w e( OR Ce, 61f)�
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
i
1'1 CANCEL/VOID PERMIT APPLICATION.
✓e REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: EL-R -C)k -- (7C7(Xi t...'
Site Address or Parcel#: 1 �'�C.�-7 n tA) P(\Q�,f
Project Name: \Y1._2 Crw n c 1i\ u ct
Subdivision Name: ( Lot#:
EXPLANATION: C 61�j4-C Q,,{ CC 'C P \ C AkiNt
Signature: - �a� CM Date: if ! 1'�\�9
Print Name: t ep f('\C m Y�
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests. �J Q r .3 0) Gf C1
/C, ?.off y.Yd 33a
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date of 17 )7 By I/
Refund Processed: Date ,/% /�+ Byre Invoice Processed: Date By
Permit Canceled: Date ,�. 9 By, -- Parcel Tag Added: Date By
I:\Building\Fonns\RegPermitAction_12051 .doc
INCITY OF TIGARD RECEIPT
ill
1 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: The Chime Cellular 402916193
Site Address: 12297 SW MAIN ST
Receipt Number: 422979 - 04/22/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2019-00074 Restricted Energy Permit 220-0000-43103 $150.00
ELR2019-00074 12%State Surcharge-Electrical 100-0000-24001 $18.00
Total: $168.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 066838 PUBLICUSER107 04/22/2019 $168.00
Payor: Lori McMurphy
Total Payments: $168.00
Balance Due: $0.00
Page 1 of 1