PFI2011-00017 r
(l'jrFL\Zy
I
City of Tigard
October 20, 2011
JRB Construction LLC
622 Lakefair Place
Keizer, OR 97303
Re: Permit No. PFI2011-00017
Dear Applicant:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address: 11555 SW 91"Ave.
Project Name: Butler
Job No.: N/A
Refund: ® Check #204284 in the amount of$300.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Work completed; refund 100% of deposit.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dia na owse
Building Division Services Supervisor
Enc.
I:\Building\Refunds\b3,1426t&W\EdRILN104,OSSk.dT4pf4 y(pregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
. " City ®f 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 Pennit 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: JRB Construction LLC DATE: 10/18/2011
622 Lakefair Place
Keizer, OR 97303 REQUESTED BY: Dianna Howse
Mike White
TRANSACTION INFORMATION:
Receipt #: 183543 Case #: PFI2011-00017
Date: 8/3/2011 Address/Parcel: 11555 SW 9151 Ave.
Pay Method: Check Project Name: Butler
EXPLANATION: Permit fee should have been accepted as cash assurance. Job inspected and complete;
refund 100% of amount paid.
'-It'EF.LJ'I�1D1 .E 'RMATIONi *�::
.4 :.:
's
_�•
�F} `ti'o F om ecei`"'t:.:. `" 'P. ..4. {. . .. .P -;�.. •.;: ,:.: :,•, � cevenue-AcouafN�R ' o `Refiind::
- '�,' :.' :..a;� "-1?'' :i;,-%•''a"- � =mss.
E�ttn 'le:.= ii1'dn Pert��'t:Fee Ex`arii le: 2300000
.._. .. ..... _ .... , .._ .,f ....�... -.-. ....
PFI Permit Fee 100-0000-43114 $300.00
TOTAL REFUND: $300.00
APPROVALS:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under $25,500 Department Manager r� .'(��Z' •f: �'`� ��
If under $50,000 City Manager
If over$50,000 Local Contract Review Board
SI' T:' NI' TI.'
R D Mt1 ,S E1V-A'D IN�ISTRA ON;' 7SE�0 L -r.• _�.,,: Y
Case Refund Processed: Date: 0 2e' // B
1:\13uildiiig\Refunds\RcftnxiRequcs,.doe x 09/01/2010
CITY OF TIGARD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 184306 - 10/20/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12011-00017 0�`/ /�E�i�iT � — �p-r �:G'pC ��// $-300.00
Total: $-300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 204284 DHOWSE 10/20/2011 $-300.00
Payor: JRB Construction LLC
Total Payments: $-300.00
Balance Due: $300.00
Page 1 of 1
CITY OF TIGA►RD RECEIPT
a 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 183543 - 08/03/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12011-00017 PFI Permit Fee 100-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1013 STREAT 08/03/2011 $300.00
Payor: JRB Construction LLC
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
f'
a Community Development
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: JRB Construction LLC
INVOICE TO: (Business or Individual)
Mailing Address: 622 Lakef iir Place
City/State/Zip: Keizer, OR 97303
Phone No.: 971-998-5746
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 #: PFI2011-00017
Site Address or Parcel #: 11555 SW 91"Ave
Project Name: Butler
Subdivision Name: Lot#:
EXPLANATION: $300.00 should have been cash assurance. The job has been inspected
Refund the $300.00
Signature: Date: 8/5/11
Mike White
Print Name:
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1-2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: 1 Date BY Rte to drain: Date IB
Refund Processed: Datc j /2,) B Invoice Processed: Date B
Permit Canceled: Date ^/ B —Parcel Tag ridded: Date B
Receipt# Date Method Amount$
1:\Building\Forms\RegPermitAction.doc Rev07/26/07