Permit /o7 Zafi-- 603t3c
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, engineering and building application fees.
Receipts, documentation and the Request for Permit Action or Refund form (if applicable) must be
attached to this form. Refund requests are due to Accela System Administrator by Friday at
5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela
System Administrator for distribution. Please allow 1 -2 weeks for processing.
PAYABLE TO: Western Plumbing Inc. DATE: 12/11/09
9460 SW Tigard Ave., Ste 101
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt #: 176022 Case #: PLM2009 -00330
Date: 11/13/09 Address /Parcel: 13075 SW Pacific Hwy
Pay Method: CreditCard Project Name: Denture Design
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: , [BUILD] Permit Fee Example: 245 -0000- 432000 $ Amount
Plumbing Permit Fee 2300000 -43101 $58.00
12% State Surcharge 1003100 -24001 6.96
TOTAL REFUND: $64.96
APPROVALS: •
If under 500(j Professional Staff (✓ 4L / �
If under $7,500 Division Manager
If under $22,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR ACCELA SYSTEM ADMINISTRATION USE ONLY
Refund Request Reviewed: Date: y' A � ; t P � By
Case Refund Processed: Date:
1: \ Building \ Refunds \RefundRequest.doc 04/13/09
,f
-- ..1 /i7/ 2009 09:43 5036849015 . WESTERN PLUMBING INC PAGE 01/01
RECEIVED
Community Development NOV 1 7 2009
,. ,,,c..o � Request fox Permit Action CITY OF TIGARD
:, 1 1 1 1 ION
TO: CITY OF TIGARD
Building Division Services ices Coo*dinatoe
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.59E19641 www.tigard-or.gov
FROM: (J Owner fl Applicant ® Contractor (] City Staff
(chock one)
REFUND OR Name:
INVOICE TO: C usiness ox lrrdividcet) , - ' to. , ; 'A , 1 ,' A 1,
Mailing Address: q ,1 4k. `~' , N.
City/State/Zip:
A t 3
Phone No.: s.ge. , If
c
PLEASE TAKE ACTION IPOR THE ITEMS) CHECKED (1):
4 CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
$ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
0 RE,.' 4OVE CONTRACTOR FROM PERMIT (do not cancel permit).
Pro t #: pi m `iczoq — OO 3Q
Site Address of Parcel #: _2:7,01 $ Clici C h
Project Name! fb _' Sal 4 i ' •
Subdivision Name: Lot #:
EXPLANATION: '7"C) �1 Q S
�, �. Signatur ; AO. . ,.. J ii #4lA r Date: f l -- L ' 1
Print Name: a.,11 a e * •fiP 1(1
1tsG�LPolis,
1. The Director or Building Official may authorize the refund of
al any fee 'attach was trront t yyly paid or collected.
b) not moor than 80% of the land use appication, .fan when an application iR withdrawn or weeded before any review effort hos been expended.
c) not more than 80% of the lend use application foe for issued permirat .
d) mot more than 8O% Of the ding pl review fee when an application is canceled befote any plan review effort has born expended .
not eme dm, su% of rht building permit roc fit issued perrnitl pier to :uty inspection requests.
2. Refunds will be return/71.1 to the ttd?jital Payer in the sane method in which payment waz teccivrd. Please allow 1.2 weeks for processing refunds.
C' 1 .'i; �.. t M 4, %v, j (mYlt TI iRtsT(: AC5i f,ra! 1 . :,d' : ":" ;t x s.'y'" `4A,
Rte to S • Adnaitt. Date Rte to Bl. • .Admin: �
Rrfuna P ooaased: Doc Date/;; . +�!J4i�
4.. . � 1nv Procctleaxt: Doe B
Permit Canccledt pate '.� •° -
Date By
Recvt tek Late Method Amount $ - _1
1 =`, ittmePymit togT"arr,:tA, main .Rev V7 /XOrf( 7
filswows.
11/12/2009 12:06 5036849015 WESTERN PLUMBING INC PAGE 01/02
Plumbing Permit Appiica iv ED
Site Utilities
City of Tigard Received 1 t
D ii i P... 0 9 . P¢111221130
11 , ul 13125 SW Hall Blvd , Tigard, OR 9.PAV 1 2 2009 ,
Plan Review
1 Mir: 503.639.4171 Fax: 503.1 a.1 . 0 Other Permit No.PdOL ADO /..er r 23
• Inspection Line: 503.639.4175 C14 TIGARD Deteiny:
TIGARD , Date Ready/By: haw: Et See Page 2 for
_ , ,. , . , Internet www .. , ..tigard , • - ur . .80v , . „ . , . N , , : . Notified/X./lethal: , . _ ... ,., , , Sannlementel Imformadon
.' L . ..‘. . ,: ',
Ei Ncw construction iii Demolition For s 'eel& lit e motion use checklist
Description tty. Ea Total
X Addition/alteration/replacement 0 Other New 1 - 2 dwellings (ineludas 100 ft. for each utility connectior
l'' .' '''....,''''''''.'-,',..va-- , ci* , ;e6$i§ovoitou , :.;;:. , f.:' , ', ,,, , , ...;: , ;; , 5 , , , ,',: , . , . , !..5 , :t, , ,..;•;',?,::;: . SFR (1) bath 31.170
[1 1- and 2-family dwelling Conunercial/industrial SFR (2) bath 437.78
-
- SFR (3) bath 500.32
0 Accessory building 0 Multi-family ,
Each additional batb/kitchen 25.02
0 Master builder 0 Other:
_Fr: sprit ( sq. ft.) -
Page 2
-;:i -.,'':„'.:..,'' ';' 0 .. 'N '''''': ' S uti es
i
Job site address: 6 diii . lil
. % .,_ Dr ll leach li
v . Catch basin or arca drain _ ,---- -
ywe, eacne, or trench drain . 18.76
18.76
City/State/ZIP:
- Tv - vo rr A `1 I
'A ‘t J Footing drain (no. linear ft.: _) Page 2
, .
51 Piv 13:13r,.. f`Yr Q- t , , Manufactured home utilities 50.03
Cross street/clirections to job site: -- TE.5/a. A..) - ____ Manholes 18.76
Rain drain connector 18.76
•, ' Sanitmy sewer (no. linear It: _.) Page 2
Storm sewer (no. linear ft.: ) Page 2
-- 7 ' Water service (no. linear ft.: ) 1 Page 2 I
Subdivision: .] Lot no.: - Fixture or item:
Tax map/parcel no.: , /e)A 6 ilacidl.ow preventer 31.27
, ';'' '..,;r:.''':'','"' ,'. i'47: ■iiiigditipkiiiiiir,f0,1(v ',' ',„ ,•, ,,' ,'1..7 Backwater valve 1151
' Clothes washer • 25.02
Dishwasher 25.02
,--_Igekl_raLA P) ) Drinking fountain 25.02 . .
Ejectors/sump _ 25.02
1Sri ',.„'i 1:: ',, e....''.'.;," .'i:,;:.;.,%,,,r):Afjgi4tift, ,, ;.., 17 . 7 ,...',:,:; , Expansion tank 1151
-
Fixturc/scwcr cap 25.02
Name: 6 s „ \Th L , As cL.
Floor drain/floor sink/bub 25.02
Address: -
Garbage disposal 25,02
City/State/ZIP:
Hose bib 25.02
Phone: ( ) t6,1 -0 1 i4 I Fax ( ) lee maker 12.51
P. XA:gr..,,y .0 1$1.. ,'', Interceptor/grcasc trap 25.02
Medical gas (value: $ ) Page 2
Business name:
Primer 12.51
Contact name:
Roof drain (conunercial) 12.51
Address:
Sink/basin/lavatory i 25.02
City/StatefZIP: Solar units (potable water) 62.54
Phone: ( ) Fax;; ( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25_02
25.02
Water heter 37.52
Business name: Western Plumbing, Inc.
Water piping/DWV 56.29
Address: 9460 SW Tigard Avenue Suite 101 Other: 25.02
City/State/ZIP: Tigard, oR 97223
- .
Subtotal
permit
Phone: (503) 639-5296 Fax: (503) 684-9015 lvfinimum fec72.50 1Q:D
Plan review (25% of permit fec)
Ca3 Lic.: 2439 Plumbing Lic. no.: 34-29FB
:._
Authorized signature: ce
07),
This permit applicatioa p l-g e °e rm T(1 1 AL t 2 Is % n PE O f t );113 o P li erni tal Til ne F d ttE wi eE) thie 11130d
..........-
Print name: Dana Jensen Date: j I ,
after it has been accepted as complete.
-
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City of Tigard, Oregon 0 13125 SW Hall Blvd. 0 Tigard, OR 97223
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December 11, 2009 . • • ,
Western Plumbing Inc.
9460 SW Tigard Ave., Ste 101
Tigard, OR 97223
Attn: Dana Jensen
Re: Permit No. PLM2009-00330
Dear Ms. Jensen:
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 13075 SW Pacific Hwy.
Project Name: Denture Design
Job No.: N/A
Refund: 1=1 Check # in the amount of $
LE Credit card "return" receipt in the amount of $64.96.
E1 Trust account "deposit" receipt in the amount of $
Notes: 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,
e•-• , „ a-A:—
Dianna Howse
Building Division Services Supervisor
Enc.
I.\ Building\ Refunds \ Adrnintstration \LtrRefund-CancelPermit.doc 01/16/07
Phone: 503.639.4171 0 Fax: 503.684.7297 0 www.tigard-or.gov 0 TTY Relay: 503.684.2772
CITY OF TIGARD RECEIPT
V
a . , . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
n i'r
Receipt Number: 176277 - 12/11/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 - 00330 $ - 64.96
Total: $ -64.96
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 713183 DHOWSE 12/11/2009 $ -64.96
Payor: William Dovers, Western Plumbing Inc.
Total Payments: $ - 64.96
Balance Due: $64.96
Page 1 of 1
• CITY OF TIGARD RECEIPT
g : 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
OP-- 6f'r:M,. j t.
Receipt Number: 176022 - 11/13/2009
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PLM2009 -00330 Sink 2300000 -43101 $25.02
PLM2009 -00330 12% State Surcharge - Plumbing 1003100 -24001 $8.70
PLM2009 -00330 Minimum Fee Adjustment - Plumbing 2300000 - 43101 $47.48
Total: $81.20
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card . 713183 DADAMSKI 11/13/2009 $81.20
Payor: William Dovers - Western Plumbing Inc
Total Payments: $81.20
Balance Due: $0.00
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•
Page 1 of 1