PFI2011-00018 •. r �yv
7� ,,
City of Tigard
November 4, 2011
Greg Brazer
12770 SW Marie Ct
Tigard, OR 97223
Re: Permit No. PFI2011-00018
Dear Mr. Brazer:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address: 12770 SW Marie Ct
Project Name: Bcllwood
job No.:
Refund: ❑ Check # in the amount of$
® Credit card "return' receipt in the amount of$750.00.
❑ Trust account"deposit"receipt in the amount of$
Notes: Project complete;refund cash assurance.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
I:\Building\RefundsI&U&&Wnfeldf,Bk;rdPdtitT4ardy/10regon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
r
e City of 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: Greg Brazer DATE: 10/28/2011
12770 SW Marie Ct.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
Mike White
TRANSACTION INFORMATION:
Receipt #: 183652 Case#: PFI2011-00018
Date: 08/12/2011 Address/Parcel: 12770 SW Marie Ct.
Pay Method: CreditCard Project Name: Bellwood
EXPLANATION: Project complete;refund cash assurance.
REFUND INFORMATION:
Fe e.Desciijition-From.Receipt, Redenue Account No.' 'Refund'
.. .
Exam le:: Biiildin Permit Fee Exam 'le: 2300000-43104 $Amount
Cash Assurance 100-0000-22000 $750.00
TOTAL REFUND: $750.00
APPROVALS:
If under$5,000 Professional Staff
If under$12,500 Division Manager �'"• l'
If under$25,500 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: Date: g
1:\Building\Refunds\Refundltequcst.doc x 09/01/2010
CITY OF TIGARD RECEIPT
q
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 184502 - 11/04/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12011-00018 $-750.00
Total: $-750.00
PAYMENT METHOD CHECK# CC RUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 021821 DHOWSE 11/04/2011 $-750.00
Payor: Greg Brazer
Total Payments: $-750.00
Balance Due: $750.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 183652 - 08/12/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12011-00018 PFI Permit Fee 100-0000-43114 $300.00
PF12011-00018 Customer Deposit 100-0000-22000 $750.00
Total: $1,050.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 021821 STREAT 08/12/2011 $1,050.00
Payor: Greg Brazer
Total Payments: $1,050.00
Balance Due: $0.00
Page 1 of 1
Is Community Development
Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 uvw.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 6.7(j,E,4q F7�f}Z ll�rt2
MailEig Address: I Z'7 7 0 ca� 6K 4YL4 X Ar--r
City/State/Zip: -a7'L- 'R I Z a -S
Phone No.: 50 3.- S" �-7 2 7
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt,if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit#: ?f: l?f: 2,011 - 000199
Site Address or Parcel #: I 7-7-7 O
Project Name:
Subdivision Name: -F7 EA.L.Uxrb Lot #:
EXP ATION: Fd/jb SO 2!1 G45W A%.-)nuc&•
`' c IT eA71-1);
Signature: Date: 2 S ((
Print Name: kid-x -fix, W d{ IM
Refund Poliev
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 8M16 of the land use application fee for issued permits
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original payer in the same method in which payment was received. Please allow 1-2 weeks for processing refunds.
• ' OFFICE USE ONLY
Rte to Sys.Admin: Date By I Rte to :Adrrun: Date
Refund Processed: Date // y �� By Invoice Processed: Date B 3,
Permit Canceled: Date/t/ Fjt— B Parcel Tag.Added: Date B
Receipt # Date Method Amount$
l:\Building\Forms\Req Ile rmirAetion.doe Rev 02/23/2011