MIS2007-00008 City of Tigard, Oregon • 13125 SW Hall Blvd. • Tigard, OR 97223
II
T I GARD
June 29,2007
•
Roger Stalick
915 Torreyview Ln.
Portland, OR 97229
Re: Permit No.MIS2007-00008
Dear Mr. Stalick
The City of Tigard has canceled the above referenced permit(s) and enclose a refund for the
following:
Site Address: 8000 SW Pfaffle St.
Project Name: Christensen
Job No.: N/a
Refund: ® Check#52040 in the amount of$374.40.
❑ Credit card "return" receipt in the amount of$
❑ Trust account "deposit" receipt in the amount of$
Notes: SDR required;applicant to resubmit for MIS and SDR at a later date. Refund 80%
of application fee.
If you have any questions please contact me at 503.718.2430.
Sincerely,
�! /4 cri Z
Dianna Howse
Permit Specialist
E nc.
I:\Building\Refunds\Administration\LtrRefund-CancelPermit.doc 01/16/07
Phone: 503.639.4171 • Fax: 503.684.7297 • www.tiPard-or.Pov • TTY Relay• sn3 KR4 7771
c y Building Division
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ix City Staff
(check one)
REFUND OR Name: p r q,
INVOICE TO: (Business or Individual) 1\(D �i�c�Q a CA
V 0 1 0 Mailing Address: 1 IS TO ffc■./ i GW L.OM
-
0/ 7 City/State/Zip: a-c,t_d- 61<-- !1 22 9
Phone No.: (s' f) a C - 3i QC)
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#: M 4 C 6)00-) - DOC=O■E
Site Address or Parcel#: a00 0 c.Uu t'-f.t F{ I,c
Project Name: Cr 2/S j-E /SE-A1
Subdivision Name: Lot#:
EXPLANATION: Ct k t L t- etiv t. vc l r<,.)i tG w.t C�j�_ Lc4-1'
w eu t`.r c.tc. ,,r-t-.r . T�e etre rt-I 04k r S p g_ � sr-43
II (rsk6M -rd's tin I S afp w+ ifAa .SOI r si c
Signature: Date: 6/4 ! )00-7
Print Name: Emi�y E hcl
I �
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) 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.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date By
Refund Processed: Date f�-/' /C 7 By 44Z Invoice Processed: Date By
Permit Canceled: Date 6V/,V/c 7 By L- Parcel Tag Added: Date By
Receipt#0 7"v.3y9 Date :52/25/0 7 Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/24/06
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 Pe- mt A ction or Rfund 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: Roger Stalick DATE: June 18,2007
915 Torreyview Ln.
Portland, OR 97229 REQUESTED BY: Dianna Howse
EAE
TRANSACTION INFORMATION:
Receipt#: 2007-2349 Case#: MIS2007-00008
Date: 5/25/07 Address/Parcel: 8000 SW Pfaffle St.
Pay Method: Check Project Name: Christensen
EXPLANATION: Requires SDR;will resubmit for MIS and SDR at a later date. Refund 80% of
appliation fee.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: [BUILD]Permit Fee Example: 245-0000-432000 $Amount
[LANDUS]Lot Line Adjustment 100-0000-438000 $325.60
[LRPF]LR Planning Surchargeq 100-0000-438050 48.80
TOTAL REFUND: $374.40
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
Y FOR TIDEMARK SYSTEM ADMINISTRATION USE ON� " y
Case Refund Processed: Date: I 4//,'�C 7 I By I
J --f
I:\Building\Refunds\RefundRequest.doc 05/23/07
i
IIV CITY OF TIGARD
5/25/2007
e 3 2:24:31PM
Tigard,OR 97223 503.639.4171
TIGARD
Receipt #: 27200700000000002349
Date: 05/25/2007
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
MIS2007-00008 [LANDUS]Lot Line Adjustment 100-0000-438000 407.00
MIS2007-00008 [LRPF]LR Planning Surcharge 100-0000-438050 61.00
Line Item Total: $468.00
Payments:
Method Payer User ID Acct./Check No. Approval No. How Received Amount Paid
Check ROGER OR PETER STALICK KJP 1010 In Person 468.00
PFAFFLE DEVELOPME
Payment Total: $468.00
Receipt.rpt Page 1 of I