SGN2012-00005 T I CARD
City of Tigard
February 23, 2012
City of Tigard
Attn: Kim McMillan
13125 SW Hall Blvd.
Tigard, OR 97223
Re: Permit No. SGN2012 -00005
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: SEG825 - corner of Hall /Pacific Hwy
Project Name: City of Tigard Flag Pole
Job No.: N/A
Refund Method: ❑ Check # in the amount of $
® Credit card "return" receipt in the amount of $165.00.
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): Refund 100% of sign permit application fee as the land use process for
flag pole will be completed under director's interpretation and downtown design review
process.
If you have any questions please contact me at 503.718.2430.
Sincerely,
X, :
Dianna Howse
Building Division Services Supervisor
Enc.
l:\ Building\ RefundslAgAtdtt rillislika1 igarelQtQt on 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
IM . . City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: City of Tigard DATE: 2/17/2012
Attn: Kim McMillan
13125 SW Hall Blvd. REQUESTED BY: Dianna Howse
Tigard, OR 97223 KJP
TRANSACTION INFORMATION:
Receipt #: 185207 Case #: SGN2012 -00005
Date: 1/18/2012 Address /Parcel: SEG825 - SW corner of Hall
and Pacific Hwy
Pay Method: CreditCard Project Name: City of Tigard Flag Pole
EXPLANATION: Refund 100% of permit fees as sign permit is not required; land use will be processed
through Director's Interpretation.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 - 43104 $ Amount
Sign Permit 100 - 0000 -43115 $144.00
Sign Permit - LRP 100 - 0000 -43117 21.00
TOTAL REFUND: $165.00
APPROVALS:
If under $5,000 Professional Staff
If under $12,500 Division Manager .7 ' / ��.�f / A
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM MINISTRATION USE ONLY
Case Refund Processed: I Date: I a /a3 / 0 2 I By:
1:\ Building \Refunds \RcfundRcyucst.doc x 09/01 /2010
V OID vf
C
a/ 3//02- Community Development
TIGARD Request for Permit Action it " / Y
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 n Contractor N City Staff
(check one)
REFUND OR Name: Kim McMillan
INVOICE TO: (Business or Individual)
Mailing Address: 13125 SW Hall Blvd
City /State /Zip: Tigard, OR 97223
Phone No.: 503 - 718 -2642
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
I I INVOICE FOR FEES DUE (attach case fee schedule and explain below).
I REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: SGN2012 -00005
Site Address or Parcel #: SEG825 _Su) oZ.'/E2. Pi9 / /C //ft4 L(—
Project Name: City of Tigard - Flag Pole
Subdivision Name: Lot #:
EXPLANATION: Please void and refund fee. Sign permit not needed. The land use
process for placement of sign pole will be done through a Director's Interpretation
and Downtown Design Review process.
Signature: FoLLAAwil3 Date: 1/24/12
Kristie Peerman
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 Admin: Date,? .22 /.z By :&V '•
Refund Processed: Date o'z ..23// s By ?ft Invoice Processed: Date By
Permit Canceled: Date _21.2 3 4,2_ By ,17- f Parcel Tag Added: Date By
Receipt # ir5 7 Date /AP /.2 Method e C Amount $ ,'ti S ,
I:\ Building \Forms \RegPermitAction.doc ev 07/26/07
g Community Development
. r , Request for Permit Action
AlGARD
TO: CITY OF TIGARD
Building Division Services Coordinator
13 "125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: Owner Applicant 1 1 Contractor X City Staff
(check one)
REFUND OR Name: Kim McMillan
INVOICE TO: (Business of Individual)
Mailing .Address: 13125 SW Hall Blvd
City /State /Lip: Tigard, OR 97223
Phone No.: 503-718-2642
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
X] CANCEL PERMIT APPLICATION.
X REFUND PERMIT FEES (attach receipt, if available).
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: SGN2012 -00005
Site Address or Parcel #: SEGS25
Project Name: City of Tigard - Flag Pole
Subdivision Name: Lot #:
EXPLANATION: Please void and refund fee. Simn permit not needed. The land use
process for placement of sign pole will be done through a Director's Interpretation
and Downtown Design Review process.
Signature: Date: 1/21/ 12
Kristie Peerman
Print Name:
Refund Policy
I. "the Director or Building Official may authorize the refund of:
a) any tee which was erroneously paid or collected.
b) not more than 80% of the and use application tee 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 130% of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) 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. .
` 0/MMVO MItrOOIt °FPICE U$E ONLY ' g garari a M 3
Rte to Sys Admin: Date By Rte to Bldg Adtnin: Date By
Refund Processecl: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:A Building \Morns \RegPermitAction.doc Rev 117/26/07
tt
i i."‘ III Ci ofTigard
� �lz y/ 'v 012
■
ry g JAN 1
Sign Permit Application CITY OF TIGARD
T 1 G A R D PLANNING /ENGINEERING
GENERAL INFORMATION
Name of Development /Project
Site
5E4 g ZS FOR STAFF USE ONLY
Address/ Street Address Permit No.: ,5 y N 2.0 1 L • 0 c3U 0 5
Location gAu- / 9
Approved By:
Suite /Bldg. # City /State Zip
T1 SAR]J Date: I /1 81, Z✓
Name Receipt #: rg 5 7.01
Property C l Ti OF T( C # z-c Map /TL #: 2 S / 0 2. A-4 O O / 0/
Owner Mailing Address Suite Zoning: 1 1 (4. .. 6 A
1' I Z.'S 514 HALL Allowable Total Area:
City /State Zip Phone
Tenant or
-r e m� O 503 "118 ` 2 2 Electrical Permit Required? ErYes ❑ No
Business C (1N o F T t G A C2.0 Building Permit Required? U4es ❑ No
Name Rev. 7/1/11
/ •' is \curpin \ masters \land use applications \ sign permit app.doc
Sign ELKeits R L PA&)iJE2.
Contractor Mailing Address Suite
f 33 2- we rRoR ow4y
City /State Zip Phone 6 . REQUIRED SUBMITTAL ELEMENTS
f 07L4#) q? 2-3 2 282. (Z (1- (Note: applications will not be accepted
Oregon Const. Cont. Board License # Exp. Date without the required submittal elements)
1678 4+ / 95 (DDOS 12./9 lI3 ❑ Completed Application Form
E Permanent ® Freestanding ❑ Freeway
Proposed ❑ 2 copies of site /plot plan, drawn to scale
Sign
❑ Temporary Roof
❑ ❑ Electronic (3 copies, if a building permit is required)
(Check all that
apply) ❑ wall
0 Other size requirement: 81/2" x 11", or 11" x 17"
❑ 2 copies of elevations, drawn to scale
g New sign? ❑ Alter to existing sign? (3 copies, if a building permit is required)
Sign Dimensions: 5 _ i PO LC size requirement: 81/2" x 11", to 24" x 36"
Total Sign Area (sq. ft.): 15 d ❑ $165.00 Fee (Permanent sign, any size)
Sign Data Total Wall Area (sq. ft = Rio ❑ $52.00 Fee (Temporary sign, any type)
(Complete all Direction Wall Faces (circle one):
items in this NOTES:
section) N S E W NE NW SE SW
Height to top of sign (feet): 5 o , • Wall signs do not need to be drawn to scale, but
Projection From Wall (inches): i o ' x (5 , must t include dimensions of wall face and sign
placement.
Materials: LD NI • Wall signs do not require site /plot plans.
Will sign have illumination? g Yes ❑ No • Freestanding signs over 6 ft. required a building
Type: ❑ Internal ® External permit.
Are there any existing freestanding or wall signs at this location,
including wall signs that overlap a tenant space?
❑ Yes g No
If "yes ", a list or diagram of all sign dimensions and square
(OVER FOR SIGNATURES)
footage must also be submitted.
City of Tigard 1 13125 SW Hall Blvd., Tigard, OR 97223 1 503- 718 -2421 1 www.tigard- or.gov 1 Page I of 2
APPLICANTS:
To consider an application complete, you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on the
front of this application in the "Required Submittal Elements" box.
NOTE: Person specified as "Applicant" shall be designated "Permittee" and shall provide financial assurance for work.
* When the owner and the applicant are different people, the applicant must be the purchaser of record or a lessee in possession with
written authorization from the owner or an agent of the owner. The owner(s) must sign this application in the space provided on the back
of this form or submit a written authorization with this application
BY SIGNING BELOW, THE APPLICANT(S) SHALL CERTIFY THAT:
• If the application is granted, the applicant will exercise the rights granted in accordance with the terms and
subject to all the conditions and limitations of the approval.
• All of the above statements and the statements in the plot plan, attachments, and exhibits transmitted
herewith, are true, and the applicants so acknowledge that any permit issued, based on this application, and
may be revoked if it is found that any such statements are false.
• The applicant has read the entire contents of the application, including the policies and criteria, and
understands the requirements for approving and denying the application.
I hereby acknowledge that I have read this application, that the information given is correct, that I am the
owner or authorized agent of the owner, and that plans submitted are in compliance with the City of Tigard.
SIGNATURES of each owner of the subject property are required.
vw�� (1 (1
Appli ignature Date
Signature of Owner /Agent Date
i►I d 3 7 r g 2 (o 4 Z
Contact Person Name Phone No.
City of Tigard 1 13125 SW Hall Blvd., Tigard, OR 97223 1 503- 639 -4171 1 www.tigard - or.gov 1 Page 2 of 2
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CITY OF TIGARD
G gt 1312 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 185207 - 01/18/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SGN2012 -00005 Sign Permit 100- 0000 -43115 $144.00
SGN2012 -00005 Sign Permit - LRP 100 - 0000 -43117 $21.00
Total: $165.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 066677 KPEERMAN 01/18/2012 $165.00
Payor: KIM MCMILLAN
Total Payments: $165.00
Balance Due: $0.00
Page 1 of 1