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Permit • 4 M ill61° T 7 City of Tigard April 14, 2011 Sandra Smith 12880 SW 121 Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 and SWR2008 -00020 Dear Ms. Smith: Our records show a refund check that was mailed to you remains outstanding and has not been submitted for payment. The check was delivered to you via the United States Postal Service and is referenced as follows: Site Address: 12880 SW 121 Ave. Project Name: Smith Check #: 60338 Amount: $9,450.20 Date Mailed: November 26, 2008 Note: Permit fees were refunded 100% as applicant was unable to connect to sewer as the elevation of the residential dwelling was too low to be servied by public sewer lateral. A voice mail message left at 503 -590 -3309 was not returned therefore this letter is mailed. Due to banking policies, this check is now invalid. Please contact me at 503.718.2430 to discuss your options. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 1:\ Building\ Refund4AZISN,'al - Wh hstaligatted ettigbrfP97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard- or.gov City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 • • m • . T I GARD. November 26, 2008 Sandra Smith 12880 SW 121st Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 & SWR2008 -00020 Dear Ms. Smith: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following. Site Address: 12880 SW 121st Ave. Project Name: Smith Job No.: N/A Refund: ® Check #60338 in the amount of $9,450.20. ❑ Credit card "return" receipt in the amount of $ • ❑ Trust account "deposit" receipt in the amount of $ Notes: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I:\ Building\ Refunds\ Administration \LtrRefund- CancelPemritdoc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 . _ ° Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) Mailing Address: 12880 SW 121 Ave VOID City /State /Zip: Tigard, OR 97223 /// ,/ f Phone No.: 503- 590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V): ® CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and exp below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLM2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121St Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A • EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008- 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ee of $6,534.11. Signature: 1 1 4 J Date: 10/27/08 -Debi Die R. Adamski Print Name: Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date By Rte to Bldg Admin: Date / B Refund Processed: Date / /?/ ,f- By Invoice Processed: Date By Permit Canceled: Date /17 9 r By Parcel Tag Added: Date By Receipt #l1r L,6 9 Date e7 29 /oP Method . � Amount $ I: \ Building \Forms \RegPermitAction.do Re 07/26/07 • 4 ON City of Tigard TIGARD Tidemark 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 Tidemark System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark System Administrator for distribution. Please allow 1 -2 weeks for processing. • PAYABLE TO: Sandra Smith DATE: November 3, 2008 12880 SW 121st Ave. Tigard, OR 97223 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2008 -669 Case #: PLM2008 -00078 & SWR2008 -00020 Date: 2/29/08 Address /Parcel: 12880 SW 121st Ave. Pay Method: Check Project Name: Smith EXPLANATION: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount [PLUMB] Permit Fee 245 - 0000 - 431000 $72.50 [TAX] 12% State Surcharge 100 - 0000 - 207020 8.70 [REMDST] Reimbursement District Revenue 500 - 0000 - 479010 6,534.00 [SWUSA] Sewer Connection Fee 500 - 0000 - 207000 2,800.00 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 TOTAL REFUND: $9,450.20 APPROVALS: If under $500 Professional Staff 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 TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: I Date: I /7-3/0" By: I ( I:\ Building \Refunds \RefundRequest.doc 05/23/07 • • 1 0 4 a CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT PERMIT #: PLM2008 -00078 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/29/2008 PARCEL: 2S 103RD -03300 SITE ADDRESS: 12880 SW 121ST AVE ZONING: R - 4.5 SUBDIVISION: LOT: JURISDICTION: TIG PROJECT: SMITH Project Description: Connecting sewer. • CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES: TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS: STORIES: WATER HEATERS: CATCH BASINS: FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS: SINKS: URINALS: GREASE TRAPS: LAVATORIES: OTHER FIXTURES: TUB /SHOWERS: SEWER LINE: ft WATER CLOSETS: WATER LINE: 100 ft DISHWASHERS: RAIN DRAIN: ft Owner: FEES SANDRA SMITH 12880 SW 121ST Description Date Amount TIGARD, OR 97223 [PLUMB] Permit Fee 2/29/2008 $72.50 [TAX] 12% State Surch 2/29/2008 $8.70 Phone : 503 -590 -3309 Total $81.20 Contractor: DU., f/L. REQUIRED ITEMS AND REPORTS Contact # : Reg #: This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: - / `�, Permiftee Signature: • Call 503.639.4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. Plumbin Per g mit Application Building Fixtures FOR OFFICE USE ONLY Received y City of Tigard 1`I ED Date/By: / T. 1517 Permit No.:Q� 6if/� t+- act Plan Review V 13125 SW Hall Blvd., Tigard, OR ' V 7 1 f tl Phone: 503.639.4171 Fax: 503. C? < - ". t Date/By: Other Permit No.'eSt i C) TI G n R D Inspection Line: 503.639.4175 q Q) .1°-16 Date Ready/By: furls: ® See Page 2 for Internet: www.tigard- or.gov t 8 - oat) Supplemental Information TYPE OF WORK WV urn 11 `�' ;5 p N FEE* SCHEDULE ❑ New construction ❑ ,,v till, i`G For spedal information use checklist Description I Qty. I Ea. I Total Addition /alteration/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath 249.20 and 2- family dwelling ❑ Commercial/industrial SFR (2) bath 350.00 ❑ Accessory building ❑ Multi- family SFR (3) bath 399.00 Each additional bath/kitchen 45.00 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities 'Job site address: j..2 i7,0 5 z4 ., ,/ L/ Aer Catch basin or area drain 16.60 City /State /ZIP: 775.4 ,-0,/ G /2 9 702 a 3 Drywell, leach line, or trench drain 16.60 Suite/bldg. /apt. no.: I Project name: 5/r7/ Footing drain (no. linear ft.: _) Page 2 Manufactured home utilities 110.00 Cross street/directions to job site: Manholes 16.60 Rain drain connector 16.60 Sanitary sewer (no. linear ft.: loci ) ( Page 2 5 Storm sewer (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Water service (no. linear ft.: ) Page 2 Fixture or item "fax map /parcel no.: Absorption valve 16.60 DESCRIPTION OF WORK Backflow preventer Page 2 544.:./ r IQ, CA, n n r jr Backwater valve 16.60 Clothes washer 16.60 Dishwasher 16.60 ❑ PROPERTY OWNER I ❑ TENANT Drinking fountain 16.60 Ejectors /sump 16.60 Name: ..Sit'it/ Sf7r' 7 /1 T Expansion tank 16.60 Address: 7,2 87G 5 4,2/ St / 4, I / Fixture /sewer cap 16.60 City /State /ZIP: T soffI D 0 /e q 7 0? Floor drain/floor sink/hub 16.60 Phone: (454:,C) g f d - 3 3 r 9 Fax: (3'a) 5 9Q _',� 304 Garbage disposal 16.60 ❑ APPLICANT ❑ CONTACT PERSON Hose bib 16.60 Ice maker 16.60 Business name: Interceptor /grease trap 16.60 Contact name: Medical gas (value: $ ) Page 2 Address: Primer 16.60 City /State /ZIP: Roof drain (commercial) 16.60 Phone: ( ) I Fax::( ) Sink/basin/lavatory 16.60 Tub /shower /shower pan 16.60 E -mail: Urinal 16.60 CONTRACTOR Water closet 16.60 Business name: OGtI N t R Water heater 16.60 Address: Other: City /State/ZIP: Subtotal Minimum permit fee: $72.50 7� �_ Phone: ( ) Fax: ( ) Residential backflow minimum permit fee: $36.25 CCB Lic.: Plumbing Lic. no.: Plan review (25% of permit fee) State surcharge (12 %ofpermit fee) '- ?r Authorized signature: I ' (. ,t �V t TOTAL PERMIT FEE Print name: f,¢ p , e 4 p Sri/ Ty Date: .<20 $7 This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. *Fee methodology set by Tri -County Building Industry Service Board. I: \ Building \Permits\PLMF- PermitApp.doc 12/27/06 440-4616T(10/02/COM/WEB) Izif-u( �_ Plumbing Permit Application - City of Tigard • -• Page 2 - Supplemental Information , Fee Schedule: Resdential Fire. Suppression Systems: Site Utilities Qty. Fee (ea) Total 'Square Footage: Permit Fee: Footing drain - I n 100' 55.00 0 to 2,000: ' ' . $115.00 Footing drain - each additional 100' 46.40 ti 3,601,to 7;200!;: $220.00 .2,001 to 3,600 $160.00 Sewer - 1st 100' ( 55.00 7;201 and greater $309.00 Sewer - each additional 100' 46.40 Water Service - 1st 100' 55.00 Medical Gas Systems: Water Service - each additional 100' 46.40 Storm & Rain Drain - 1st 100' 55.00 Valuation: Permit Fee: $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 46.40 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for each Fixture or Item Qty. Fee (ea) Total additional $100.00 or fraction thereof, to and including $10,000.00. Commercial Back Flow Prevention Device 46.40 $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for Residential Backflow Prevention Device each additional $100.00 or fraction thereof, to (minimum permit fee $36.25) 27.55 and including $25,000.00. Rain Drain, single family dwelling 65.25 $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for Inspection of existing plumbing or each additional $100.00 or fraction thereof, to and including $50,000.00. specially requested inspections - per hour 72.50 Subtotal: $50 and up $742.00 for the first $50,000.00 and $1.20 for each additional $100.00 or fraction thereof. Fixture Work: Plan Review for Plumbing Installations Are you capping, adding or replacing fixtures? If "yes ", Plan review is required for any of the following. please indicate work performed by fixture. Failure to Please check all that apply. accurately report fixtures could result in increased sewer fees *. ❑ Any new commercial building with water service 2" and Quantity by (Fixture) Work Performed greater, except systems designed and stamped•by licensed Fixture Type: Replace engineer. Previous Capped Added Existing ❑ New exterior plumbing site utilities for any complex structure Baptistry/Font as defined in OAR918- 780 -0040. Bath - Tub /Shower ❑ Medical gas and vacuum systems for health care facilities. - Jacuzzi/Whirlpool ❑ Any multipurpose fire sprinkler system. Car Wash -Each Stall ❑ Any complex structure as defined in OAR918- 780 -0040. -Drive Thru Cuspidor /Water Aspirator Submit 2 sets of plans with any of the above. Dishwasher - Commercial - Domestic Drinking Fountain • Isometric or Riser Diagram Eye Wash ❑ Isometric or riser diagram is required for new buildings Floor Drain/sink - 2" that meet the qualifications above. -4" Car Wash Drain Garbage - Domestic Comments regarding fixture work: Disposal - Commercial - - Industrial Ice Mach. /Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley *Note: If the fixture work under this permit results in an - Commercial increase of sewer EDUs, a sewer permit will be issued and - Service fees assessed for the sewer increase must be paid before the Swimming Pool Filter plumbing permit can be issued. Washer - Clothes Water Extractor Water Closet - Toilet Urinal Other Fixtures: 1:\ Building \Permits\PLM- PermitApp.doc 12/27/06 !a_ --- i 0 1 1 4 Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) Mailing Address: 12880 SW 121' Ave V 0 1 0 City/State /Zip: Tigard, OR 97223 /// / Phone No.: 503 -590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ® CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and a piaibelow). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLM2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121" Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008- 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ee of $6,534.11. OF Signature: 1 / ii 4 I , Date: 10/27/08 Irkf bie R. Adamski Print Name: Refund Policy 1. the Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fcc when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date By Rte to Bldg Admin: Date %l 3 i-.' B . -: " Refund Processed: Date /�,?/ By , 9 - Invoice Processed: Date By Permit Canceled: Date /�j!! 0 f By . j • Parcel Tag Added: Date By Receipt #a•--46 9 Date 29 /pP Method '..4.4,,,_ Amount $ I: \ Building \forms \RegPcrmitAction.do Re 07 /26/07 • la REM TO: Brian Blalock City of Tigard FROM: Sandra T. Smith 12880 SW 121st Avenue Tigard, OR 97223 (503) 590 -3309 RE: REQUEST FOR PERMIT EXTENSIONS Sewer Connection Permit # SWR2008 -0020 Plumbing Permit # PLM2008 -0078 I need an extension on these permits due to my inability to locate a contractor. Contractors that have come on site to provide bids are put off by the "iffy" elevation /slope degree for flow to the sewer connection. L i(e) Thank you for your consideration - G Sandra T. Smith August 29, 2008 • Er • . CITY OF TIGARD • 2/292008 13125 SW Hall Blvd. I2:00:I 3PM • • Tigard, OR 97223 5(13.639.4171 TIGARD Receipt #: 27200800000000000669 Date: 02/29/2008 Line Items: • Case No Trait Code Description Revenue Account No Amount Paid PLM2008 -00078 [PLUMB] Permit Fee 245- 0000 - 431000 • 72.50 PLM2008 -00078 [TAX] 12% State Surcharge . 100- 0000 - 207020 8.70 REMDST Reimbursement District Revenue - 6,534.0000 @ $1.0000 500- 0000 - 479010 6,534.00 SWR2008 -00020 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 2,800.00 SWR2008 -00020 [SWINSP] Sewer Inspection Fee 245- 0000 - 44 35.00 Line Item Total: $9,450.20 Payments: Method Payer User ID Acct. /Check No. Approval No. Flow Received Amount Paid Check SANDRA T. SMITI -I BTT 2459 In Person 9,450.20 Payment Total: $9,450.20 ,. ckcccipt.rhi Page I or I • • . B RE(O'n RECOPY TO: Brian Blalock �� City of Tigard FROM: Sandra T. Smith 12880 SW 121st Avenue Tigard, OR 97223 (503) 590 -3309 RE: REQUEST FOR PERMIT EXTENSIONS Sewer Connection Permit 41 SWR2008 - 0020 Plumbing Permit # PLM2008 - 0078 I need an extension on these permits due to my inability to locate a contractor. Contractors that have come on site to provide bids are put off by the "iffy" elevation /slope degree for flow to the sewer connection. r , Thank you for your consideration � U Sandra T. Smith August 29, 2008 C ITY OF TIGARD PLUMBING PERMIT ° •` ` COMMUNITY DEVELOPMENT PERMIT #: PLM2008 - 00078 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/29/2008 PARCEL: 2S103BD -03300 SITE ADDRESS: 12880 SW 121ST AVE ZONING: R -4.5 SUBDIVISION: LOT: JURISDICTION: TIG PROJECT: SMITH Project Description: Connecting sewer. • CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES: TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS: STORIES: WATER HEATERS: CATCH BASINS: FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS: SINKS: URINALS: GREASE TRAPS: LAVATORIES: OTHER FIXTURES: TUB /SHOWERS: SEWER LINE: ft WATER CLOSETS: WATER LINE: 100 ft DISHWASHERS: RAIN DRAIN: ft Owner: FEES SANDRA SMITH 12880 SW 121ST Description Date Amount TIGARD, OR 97223 • [PLUMB] Permit Fee 2/29/2008 $72.50 • [TAX] 12% State Surch 2/29/2008 $8.70 Phone : 503 -590 -3309 Total $81.20 Contractor: • REQUIRED ITEMS AND REPORTS Contact # : • Reg #: This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. • Issued By: f j Permittee Signature: , Call 503.639.4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. � CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT PERMIT #: PLM2008 - 00078 TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/29/2008 PARCEL: 2S 103RD - 03300 SITE ADDRESS: 12880 SW 121ST AVE ZONING: R -4.5 SUBDIVISION: LOT: JURISDICTION: TIG PROJECT: SMITH Project Description: Connecting sewer. CLASS OF WORK: ALT GARBAGE DISPOSALS: MOBILE HOME SPACES: TYPE OF USE: SF WASHING MACH: BACKFLOW PREVNTRS: OCCUPANCY GRP: R3 FLOOR DRAINS; TRAPS: STORIES: WATER HEATERS: CATCH BASINS: FIXTURES LAUNDRY TRAYS: SF RAIN DRAINS: SINKS: URINALS: GREASE TRAPS: LAVATORIES: OTHER FIXTURES: TUB /SHOWERS: SEWER LINE: ft • WATER CLOSETS: . WATER LINE: 100 ft DISHWASHERS: RAIN DRAIN: ft Owner: FEES SANDRA SMITH 12880 SW 121ST Description Date Amount TIGARD, OR 97223 • [PLUMB] Pennit Fee 2/29/2008 $72.50 [TAX] 12% State Surch 2/29/2008 $8.70 Phone : 503 -590 -3309 Total $81.20 • Contractor: REQUIRED ITEMS AND REPORTS Contact # : Reg #: This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable laws. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 0001 -0010 through OAR 952 - 0001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: <�� �- -~� . Permittee Sign ature: l � ?" Call 503.639.4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. 17! CITY OF TIGARD 2/29 13125 SW Ilan Blvd. 12:00:1 3PM • 'Tigard, OR 97223 503.039.4171 TIGARD Receipt #: 27200800000000000669 Date: 02/29/2008 Line Items: Case No Tran Code Description Revenue Account No Amount Paid PLM2008 -00078 [PLUMB] Permit Fee 245- 0000 -43 1000 72.50 PLM200S -00078 [TAX] 12% State Surcharge 100- 0000 - 207020 8.70 REMDST Reimbursement District Revenue - 6,534.0000 @ $1 .0000 500 - 0000 - 479010 6,534.00 SW R2008-00020 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 2,800.00 SW122008 -00020 [SWINSP] Sewer Inspection Fee 245- 0000 - 44 1001 35.00 Line Item Total: $9,450.20 Payments: Method Payer User II) Acct. /Check No. Approval No. How Received Amount Paid Check SANDRA 1'. SMITH BTT 2459 In Person 9,450.20 Payment "total: $9,150.2( • clteccipliv P:nte I or I • . " t!, CITY • O.F TIGA 10/24/2008 • . : 4 _ 131 -5 SW Hall Blvd. 2:29:44I'M 4 , Tigard. Olt 97223 503.639.4171 '6.1GARD - Receipt #: 27200800000000000669 Date: 02/29/2008 Line Items: Case No Trail Code Description Revenue Account No Amount Paid PLM200S -00078 [I'LUMI3] Permit Fee 245 72.50 PLM200S -0007$ [TAX] I2'1 State Surcharge 100 -0000- 207020 8.70 REM DST Reimbursement District Revenue - 6,534.0000 cis S1.0000 500- 0000 - 479010 6,534.00 SW122008- 00020 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 2 ,800.00 SWR2008 -00020 [SWINSP] Sewer I nspection Fee 245 0000 - 441001 35.00 Line hem Total: $9,450.20 Payments: Method Payer User II) Acct. /Check No. Approval Nu. Flow Received Ailunuil Paid Check SANDRA 1'. SMITH BTT 2459 In Person 9,450.20 • Payment Total: $9,450.20 :r�,riai rp, I'a I .11 I 4 *015:j City of Tigard April 14, 2011 Sandra Smith • 12840 SW 121°` Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 and SWR2008 -00020 Dear Ms. Smith: Our records show a refund check that was mailed to you remains outstanding and has not been submitted for payment. The check was delivered to you via the United States Postal Service and is referenced as follows: Site Address: 12880 SW 121 Ave. Project Name: Smith Check #: 60338 Amount: $9,450.20 Date Mailed: November 26, 2008 Note: Permit fees were refunded !00% as applicant was unable to connect to sewer as the elevation of the residential dwelling was too low to be servied by public sewer lateral. A voice mail message left at 503 - 590 -3309 was not returned therefore this letter is mailed. Due to banking policies, this check is now invalid. Please contact me at 503.718.2430 to discuss your options. Sincerely, Dianna Howse Building Division Services Supervisor Enc. • \ Buildin \Refundsi niab k aubnRkTiagattcloOttigt1097223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard- or.gov l Bank Reconciliation Checks By Date a a 03/21 /2011- 9:27 AM TIGARD User: kathyge Outstanding Checks Check No Check Date Name Comment Module Clear Date Amount 58273 07/11/2008 Teresa Trexler AP 15.00 58515 07/23/2008 Stephen Allen Barry Jr AP 35.00 58716 08/05/2008 Steven P Naylor AP 25.00 58872 08/07/2008 Jodi Dian Rosenberg AP 75.00 58969 08/21/2008 Kenneth R Erickson AP 75.00 59046 08/26/2008 Russell E Swinhart AP 60.00 59535 09/24/2008 Robert Rohlf AP 5.00 59780 10/07/2008 RAR Communications AP 150.00 59831 10/10/2008 Shubhangi Vivek Sathe AP 15.00 59906 10/20/2008 Scott Timothy Koopman AP 35.00 60011 10/28/2008 Richard Anthony Jimenez AP 5.00 60048 10/28/2008 Dylan B Dart -7 0 `v 1 ( { ., AP 15.99 60338 11/13/2008 Sandra Smith -- `,L: AP L(C� 9,450.20 60544 11/24/2008 PAULINE BECK � CZ AP Gl'� a 1 59.54 Sal 61118 01/06/2009 , Rodney W Morse AP 60.00 61606 02/06/2009 Class Act Uniforms S � Al' 208.00 61928 02/25/2009 Columbia Pacific AFS $ u) AP 157.50 62027 03/05/2009 Ariel Stefan Aurich AP 20.00 62154 03/12/2009 Roger Stover Wiley AP 0 O ng Co 60.00 62265 03/19/2009 Colorado Dept of Revenue Al' 0 3 -, 2 .70 62293 03/19/2009 Metropolitan Utility AP �� � � I� - 75.00 � 100.00 62311 03/19/2009 Sara Chacon 2 AP L L(c- (� I l 62349 03/23/2009- Bonita Court - 36 LLC V 7 r �'� �' AP / k- r. 0 08,428.56 (Y `1 CJ 62424 03/30/2009 California Pizza Kitchen Al' ,� ei r pt) 250.00 62536 04/06/2009 BinHost Technologies LLC AP I v v \> 48.00 62591 04/10/2009 Matthew Ryan McCarthy Al' L� 15.00 62647 04/10/2009 LeMay Mobile Shredding Al' V C 160.00 62774 04/16/2009 Jarret Gross AP 15.00 62857 04/30/2009 Corey Saffer PR 0.01 63009 05/07/2009 Paul William Vogel AP 25.00 63012 05/07/2009 Terrence Stephen Terry AP 25.00 63080 05/07/2009 Providence Occupational Health AP 175.50 63081 05/07/2009 Random House Inc AP 88.00 63087 05/07/2009 Group Mackenzie AP 100.00 . 63509. 05/22/2009 Demetria Corvallis Hunt AP 25.00 63515 05/22/2009 Terry Lynn Raybould AP 25.00 63879 06/16/2009 Victor Garcia Osorio AP 275.00 63998 06/26/2009 Warren Adolph Johnson AP 6.00 64017 06/26/2009 Erik Kyle Steen AP 25.00 64128 06/26/2009 J B & B CONSTRUCTION AP 5.90 64170 06/30/2009 Michael Barmache AP 25.00 Total $20,420.90 Total Checks: 41 BR - Checks by Date (03/21/2011 - 9:27 AM) Page 1 i a ° Building Division Request for Refunds TIGARI) TO: Phyllis Harris OK' I . FROM: Dianna Howse DATE: November 3, 2008 SUBJECT: Refund Requests for the week of 10/27/08 Please process the attached expenditure requests and return checks and this memo to me for disbursement: Refund Date Check Date Check Date of Case # or Refund Check Routed Mailed Payable To Receipt # Receipt Description Amount (Finance) (Building) Sandra Smith 2008 -669 2/29/08 PLM2008 -00078 $9,450.20 //t .. / i- � ""C SWR2008 -00020 / o7 / g . If you have any questions please contact me at x2430. Thank you. l: \Building\ Refunds \Administration \RouteCheckRequests.doc 01/16/07 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 I t MAL 'LiiTI,G,7•4 • November 26, 2008 Sandra Smith 0 - 12880 SW 121- Ave. Tigard, OR 97223 Re: Permit No. PLM2008-00078 & SWR2008-00020 Dear Ms. Smith: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: • Site Address: 12880 SW 121st Ave. Project Name: Smith Job No.: N/A Refund: El Check #60338 in the amount of $9,450.20. :I Credit card "return" receipt in the amount of $ El Trust account "deposit" receipt in the amount of $ Notes: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. If you have any questions please contact me at 503.718.2430. Sincerely, • • _ - Dianna Howse Building Division Services Supervisor Enc. \ Building \ Refunds \ Administration \ UrRefund-CancelPermitdot 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard-or.gov • TTY Relay: 503.684.2772 City of Tigard TIGARD Tidemark 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 Tidemark System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Sandra Smith DATE: November 3, 2008 12880 SW 121' Ave. Tigard, OR 97223 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2008 -669 Case #: PLM2008 -00078 & SWR2008 -00020 Date: 2/29/08 Address /Parcel: 12880 SW 121St Ave. Pay Method: Check Project Name: Smith EXPLANATION: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: [BUILD] Permit Fee Example: 245- 0000 - 432000. • • $ Amourit • [PLUMB] Permit Fee 245- 0000 - 431000 $72.50 [TAXI 12% State Surcharge 100- 0000 - 207020 8.70 [REMDST1 Reimbursement District Revenue 500 - 0000 - 479010 6,534.00 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 2,800.00 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 TOTAL REFUND: $9,450.20 APPROVALS: If under $500 Professional Staff / - t IE under $7,500 Division Mana g er VY If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board • FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY _ Case Refund Processed: I Date: I // �0,�' By: I 05/23/07 • Fie: ci'i' \' OF ��'Ic k I) 1 0/24 f' „ : 1 { � V 11 Blvd. 2:29:44 I'M %' 'I'iganl, Ult 97223 503.639.4171 Receipt #: 27200800000000000669 E)alc: 02 /29/2008 Line Ilenws: Case NIP ' 11'40 Code I)escripliuu Revenue Accnunl Ni, i Alnuuul I':►itI I 11007\ [PLUMB' Permit Fee 245 -0000- 431000 72.50 I'LM2008-0007ti [TAX] 12% State StlreIlart e 100-0000-2070 \.711 RLMDST Reimbursement Dislriel Revenue - 6,534.0000 (i) ti I.0000 500- 0000 - 479010 6,53 4.011 S \-VR 000_ [SWUSA I Sewer Com►eclion Fee 500 -0000- 207001) 2,X00.01) SWR2008- 00(12( [S \VINSI'I Sewer Inspection Fee 245 -0000- 441001 35.00 Line Ilene Tulal: $9,450.21) I'avlllcnls: 1\Ielhud Paver User II) Acct/Check Nu. Approval Ni,. How Received Arnow', 1'aid Check SANDRA T. SMITH L3TT 2459 In Person 9,450.20 I'avntcnl 'I'ul:ll: $9,450.211 I'. 1 .11 1 • CITY OF TIGARD RECEIPT 114 n . 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 2008 -669 - 11/03/2008 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2008 -00078 Refund - [PLUMB] Permit Fee 245 - 0000 - 431000 $ -72.50 PLM2008 -00078 Refund - [TAX] 12% State Surch 100 -0000- 207020 $ -8.70 Total: $ -81.20 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Other TAAA CONV 11/03/2008 $ -81.20 Payor: Total Payments: $ -81.20 Balance Due: $0.00 Page 1 of 1 CITY OF TIGARD RECEIPT n I:. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 2008 -669 - 11/03/2008 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID SWR2008-00020 Refund - [SWUSA] Sewer Connect 500 -0000- 207000 $- 2,800.00 SWR2008 -00020 Refund - [SWINSP] Sewer Inspec 245-0000-441001 $ -35.00 Total: $- 2,835.00 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Other TAAA CONV 11/03/2008 $- 2,835.00 Payor: Total Payments: $- 2,835.00 Balance Due: $0.00 Page 1 of 1 Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner n Applicant ❑ Contractor ® City Staff (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) V ® Mailing Address: 12880 SW 121" Ave City /State /Zip: Tigard, OR 97223 /,/5/4'f 41 7/ 1 Phone No.: 503 -590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ® CANCEL PERMIT APPLICATION. • REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and ee piait..below). H REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLIN,I2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121" Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A • EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008- 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ‘ of $6,534. . . Signature: ( ( j Date: 10/27/08 bie R. Adamski Print Name: Refund Policy 1. The Director or Building Official may authorize the refund of a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80° /n of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY: Rte to Sys Admire: Date By Rte to Bldg Admin: Date , Refund Processed: Date ///,7 % f- By — Invoice Processed: Date By Permit Canceled: Date / //3 0, By Parcel Tag Added: Date By Receipt #4? -,1.. 9 Date /a 2q / C� Method � � C Amount $ I:\ Building \Forms \RegPermitAction.do Re 07/26/07 . r % 1 Dianna Howse I D 7� �u/Ao?e(g .D00a0 From: Dianna Howse Sent: Thursday, November 10, 2011 8:34 AM To: Angela McCoy Subject: RE: Bank Reconciliation - Outstanding Checks Update Thank you. I will contact Ms. Smith by phone and will follow up with a "certified" letter of instructions. Hopefully she will listen to her v -mail and read her mail. + , Dianna M P / � From: Angela McCoy ' �( '� Sent: Thursday, November 10, 2011 8:31 AM n/ To: Dianna Howse v i ' , Subject: RE: Bank Reconciliation - Outstanding Checks Update • �/ 1. s l � e � / • Good Morning: r e / I n �°' She can call 503 - 986 -5200 and they can help her with the claims process. Online it says it can take up to 12 weeks for processing so the sooner she calls the better. Angela © From: Dianna Howse Sent: Wednesday, November 09, 2011 3:56 PM To: Angela McCoy Cc: Amy Lawson Subject: RE: Bank Reconciliation - Outstanding Checks Update Angela, Thank you for the information. I did not know about the annual unclaimed property date. I will let her know that she has to contact the state. Can you please provide me with a phone number for her to call? Thanks again for your help with this. Dianna From: Angela McCoy Sent: Wednesday, November 09, 2011 3:08 PM To: Dianna Howse Cc: Amy Lawson Subject: RE: Bank Reconciliation - Outstanding Checks Update Dianna: Unfortunately the check for this has already been issued to the state as unclaimed property. I had sent Ms. Smith a letter regarding this issue back on August 16 explaining that this check was still showing in our records as owing and un- cashed. She never responded to my letter. At this point in time Ms. Smith will need to contact the state's unclaimed property division in order to receive her funds. All Unclaimed Property is due to be turned in to the state no later than 1 November 1st of every year. So this check was cut and mailed to them on 10 -26 -2011. They should have received it by now. Had we heard from her earlier we would have been able to hold it and reissue the check. Let me know if you need any further info on this. Angela © From: Amy Lawson Sent: Wednesday, November 09, 2011 2:50 PM To: Angela McCoy Subject: FW: Bank Reconciliation - Outstanding Checks Update Amy Lawson Accounting Supervisor City of Tigard 503 - 718 -2497 From: Dianna Howse Sent: Wednesday, November 09, 2011 2:47 PM To: Amy Lawson Cc: Lora Garland; Mark VanDomelen; Kathy Gende Subject: Bank Reconciliation - Outstanding Checks Update On March 21, 2011, Kathy Gende ran a report of outstanding checks for reconciliation. I researched two of the checks on this report and following is an update. On this report, there was a check for $8,428.56 that was issued on 03/23/2009 to Bonita Court — 36LLC, but it was never cashed. In April, 2011, I found the engineering case file that contained the original check. There were notes in the file to engineering staff to find a new address to send the check, but the check was never sent. A new check was cut and sent to the correct address to close this case. There was also a check for $9,450.20 that was issued on 11/13/2008 to Sandra Smith. I processed the original request to void the plumbing and sewer connection permits and refund 100% of the fees paid as Ms. Smith was unable to connect to sewer as the elevation of the residence was too low to be served by the sewer lateral. I mailed the check to Ms. Smith on November 26, 2008, however the check was never cashed. Based upon the outstanding checks report, on April 14, 2011, I sent a letter to Ms. Smith regarding the check and asked that she contact me. On April 20, 2011, I called and left a v -mail message to return my call, and followed up with another call and v -mail message on June 10 Yesterday, I decided to call Ms. Smith one more time before requesting the funds be sent to the state, and earlier today she called me! Ms. Smith still has the check and she kept it because she did not believe what the contractor told her and thought she could find someone else to do the work. Ms. Smith will be mailing the check to my attention, and I will process a request to replace the check within the next 2 weeks. Ms. Smith was very thankful that I pursued this matter as she now has an immediate need for the funds and she apologized for not getting back to me sooner. What a great day! Dianna Howse Building Division Services Supervisor City of Tigard 503.718.2430 2 ` DISCLAIMER: E -mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E -mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule." 3 - - l> 19//___Cl. /i (_. 0 7) - - - - / Z - r- - !h,.c:/ __i---e-6 kcz am- * -5_z_e_ -- — -- - - - ._.4 __ w i// . ` - 7d-c . ` .%l- .,. _ . a-- -1-..� -- - - - -- -- - - _ 4,// - p . G!_ -U?-1t - - -- - - - - - 0 e //1 _ ..5 : /4/.1 - -- - - - - - -- - ------ ---- - - - ------- --- - - - - - LEFT _. r/� Sc, -590 -3309 - - -- -- GIFT tl @ 5O3- - -- — - -- - - - - -- - — �0 -33o 9 / // 8 /// & WO!.3 / - - so 3 -590 -3 3 0 9 - - - -- -- - - - - - -- -- 1 077- / / / /o //, • City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223 • Ill •• • . T I GARD November 26, 2008 Sandra Smith 12880 SW 121st Ave. Tigard, OR 97223 Re: Permit No. PLM2008 -00078 & SWR2008 -00020 Dear Ms. Smith: The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the following: Site Address: 12880 SW 121st Ave. Project Name: Smith Job No.: N/A Refund: ® Check #60338 in the amount of $9,450.20. ❑ Credit card "return" receipt in the amount of $ . ❑ Trust account "deposit" receipt in the amount of $ . Notes: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. I:\ Building\ Refunds\ Administration \LtrRefund- CancelPemut.doc 01/16/07 Phone: 503.639.4171 • Fax: 503.684.7297 • www.tigard- or.gov • TTY Relay: 503.684.2772 Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone:_ 503.718.2430 Fax:_ _503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff (check one) REFUND OR Name: Sandra T. Smith INVOICE TO: (Business or Individual) ® Mailing Address: 12880 SW 121St Ave V 'i " /i City /State /Zip: Tigard, OR 97223 /V 5A1 / Phone No.: 503 - 590 -3309 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): ® CANCEL PERMIT APPLICATION. ® REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and exp elow). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: PLM2008 -00078 & SWR2008 -00020 Site Address or Parcel #: 12880 SW 121s Ave Project Name: Smith Subdivision Name: N/A Lot #: N/A EXPLANATION: House too low to be served by sewer lateral. Void PLM2008 -00078 & SWR2008 00020. Per Brian Blalock, refund 100% of all permit fees, plus the paid Reimbursement District #30 ee of $6,534. A. Signature: t / a / .f 1,(4,4 ) Date: 10/27/08 ie R. Adamski Print Name: Refund Policy 1. The Director or Building Official may authorize the refund of a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date B Rte to Bldg Admin: Date S • - B ! Refund Processed: Date II .7 i t By , — Invoice Processed: Date / By Permit Canceled: Date f p B r.� Parcel Ta: Added: Date By Receipt #Ltd �6 q Date a 29 or Method 6 "" �� Amount $ I:\ Building \Forms \RegPerrnitAction.do Re - 07/26/07 �1 City of Tigard TIGARD Tidemark 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 Tidemark System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Tidemark System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Sandra Smith DATE: November 3, 2008 12880 SW 121st Ave. Tigard, OR 97223 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 2008 -669 Case #: PLM2008 -00078 & SWR2008 -00020 Date: 2/29/08 Address /Parcel: 12880 SW 121st Ave. Pay Method: Check Project Name: Smith EXPLANATION: Unable to connect to sewer as house elevation is too low to be served by lateral. Refund 100% of permit fees and reimbursement district #30 fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No Refund Example: [BUILD] Permit Fee Example: 245- 0000 - 432000 $ Amount [PLUMB] Permit Fee 245- 0000 - 431000 $72.50 [TAX] 12% State Surcharge 100- 0000 - 207020 8.70 [REMDST1 Reimbursement District Revenue 500- 0000 - 479010 6,534.00 [SWUSA] Sewer Connection Fee 500 - 0000 - 207000 2,800.00 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 TOTAL REFUND: , $9,450.20 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager C If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: I Date: I % /,�'S O ? By: I I: \Building \Refunds \RefundRequest.doc 05/23/07 Er CITY OF TIGARD 10/24/2003 13125 SW Hall Bled. 2:29:441%4 Tigard, OR 97223 5113.639.4171 TIGARD . • Receipt #: 27200800000000000669 Date: 02 /29/2008 Line Items: Case No Tran Code Description Revenue Account No Alumni( Paid PLM200S -00073 [PLUMB] Permit Fee 245- 0000 - 431000 72.10 PLM2008-00073 [TAX] 12`if State Surcharge 100 -0000- 207020 8.70 REMDST Reimbursement District Revenue - 6,534.0000 ci! $1.0000 500 -0000 - 479010 6,534.00 S W R200S -00020 [S W USA] Sewer Connection Fee 500- 0000 - 207000 2 ,800.00 SWR200S -00020 [SWINSP] Sewer Inspection Fee 245- 0000 - 441001 35.00 • Line Item Total: $9,450.20 Payments: Method Payer User I D Acct. /Check No. Approval No. How Received Amount Paid Check SANDRA T. SMITH BTT 2459 In Person 9,450.20 • Payment Total: $9,450.20 crecoot ,-pi P:Ige I u1 I Case Activity Listing r [10/8/2008 L9:45:18AM �•�'� CCEL/ � �- Case #: fLM2008 -00078 Assigned Done Updated Activity Description Date 1 Date 2 Date 3 Hold Disp To By By Notes PLM1010 Application received 2/29/2008 None RECD BTT 2/29/2008 BLD PLM1020 Permit created 2/29/2008 None DONE BTT 2/29/2008 BLD PLM 1030 Check for parcel tags 2/29/2008 None DONE BTT 2/29/2008 BLD PLM1280 Issue permit 2/29/2008 None DONE BTT 2/29/2008 BLD PLM 1540 Permit extension 9/3/2008 None DONE BTT 9/3/2008 180 - day extension granted per Brian granted BTT Blalock. exQ1 �-- Page 1 of 1 CaseActivity ..rpt Bank Reconciliation Checks By Date a 03/21 /2011- 9:27 AM T1GARD User: kathyge Outstanding Checks Check No Check Date Name Comment Module Clear Date Amount 58273 07/11/2008 Teresa Trexler AP 15.00 58515 07/23/2008 Stephen Allen Barry Jr AP 35.00 58716 08/05/2008 Steven P Naylor AP 25.00 58872 08/07/2008 Jodi Dian Rosenberg AP 75.00 58969 08/21/2008 Kenneth R Erickson AP 75.00 59046 08/26/2008 Russell E Swinhart AP 60.00 59535 09/24/2008 Robert Rohlf AP 5.00 59780 10/07/2008 RAR Communications AP 150.00 59831 10/10/2008 Shubhangi Vivek Sathe AP 15.00 59906 10/20/2008 Scott Timothy Koopman AP 35.00 60011 10/28/2008 Richard Anthony Jimenez C. AP �p 5.00 / 60048 10/28/2008 Dylan B Dart �qq 0 O AP to U" 15.99 • . V 60338 11/13/2008' Sandra Smith .�- (-2-5... 2 ��� AP ca.- Il l 9 ,450.20 60544 1 1 PAULINE BECK W AP Gl'r ft 1 fir✓ .v 59.54 61118 01/06/2009 , Rodney W Morse c .Z.) U AP 11 0 f � � G i�/ 11 60.00 61606 02/06/2009 Class Act Uniforms v�� AP � � H 1 � 1 00 61928 02/25/2009 Columbia Pacific AFS W AP ✓ � L U" S" 5 .50 62027 03/05/2009 Ariel Stefan Aurich AP e f°U�1' 20.00 62154 03/12/2009 Roger Stover Wiley AP klA 000g (o 60.00 62265 03/19/2009 Colorado Dept of Revenue AP ,�?,, '°y 17 3 - C 2.70 62293 03/19/2009 Metropolitan Utility AP r �� i' 1 films 75.00 62311 03/19/2009 Sara Chacon �� AP L. Al l•G 100.00 62349 03/23/2009 Bonita Court - 36 LLC _ 1 B _ ^ 6 � AP • G (j„ F 0 0 8,428.56 62424 03/30/2009 California Pizza Kitchen '5„J � AP IS I 250.00 62536 04/06/2009 BinHost Technologies LLC A L v, I'� 7 / • 48.00 62591 04/10/2009 Matthew Ryan McCarthy AP O C 8 / 15.00 62647 04/10/2009 LeMay Mobile Sh AP t� t L I 160.00 62774 04/16/2009 Jarret Gross AP f jE / 15.00 62857 04/30/2009 Corey Saffer PR 0.01 63009 05/07/2009 Paul William Vogel AP S 25.00 63012 05/07/2009 Terrence Stephen Terry AP 25.00 63080 05/07/2009 Providence Occupational Health AP 175.50 63081 05/07/2009 Random House Inc AP 88.00 63087 05/07/2009 Group Mackenzie AP 100.00 63509 05/22/2009 Demetria Corvallis Hunt AP 25.00 63515 05/22/2009 Terry Lynn Raybould AP 25.00 63879 06/16/2009 Victor Garcia Osorio AP 275.00 63998 06/26/2009 Warren Adolph Johnson AP 6.00 64017 06/26/2009 Erik Kyle Steen AP 25.00 64128 06/26/2009 J B & B CONSTRUCTION AP 5.90 64170 06/30/2009 Michael Barmache AP 25.00 Total $20,420.90 Total Checks: 41 BR - Checks by Date (03/21/2011 - 9:27 AM) Pagc 1 4 • V , . I ; • • • • 1 • I. •D • 1-1\ .Spc °7=6 LL SS,Q?Ab Got • ... •