Permit • City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: MP Plumbing Co. DATE: 3/31/2014
Attn: Cindy Crivellone
PO Box 393 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt#: 195331 Case#: PLM2014-00078
Date: 3/24/2014 Address/Parcel: 9625 SW Serena Way
Pay Method: CreditCard Project Name: Arnet
EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNATURES/DATE:
IE under$5,000 Professional Staff
If under$12,500 Division Manager
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: .s/3///y I By: I�
1:\Building\Refunds\RcfundRequest.doc x 09/01/2010
FROM MP Plumbing (TUE)MAR 25 2014 14:37/ST. 14:38/No.9309294187 P 2
VOID �I(�40'
City of Tigard • COMMUNITY DF,VELOPMI:NT DEPARTMENT n
Re q uest Permit Action 3/3�.
. i 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
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:
INVOICE TO: (Business or individual) > 1wrm'bl v..\
Mailing Address: D R&. 'b
City/State/Zip: ACI ri\ -c ro.S, Oe. q:1(1)6
Phone No.: — 6S5 `�,l p I
PL SE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
VANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ?Lc \ 011-1 --Opp 1
Site Address or Parcel#: 9 l t,p 5 L��SC/y eiyZ0.
Project Name: \)UA J`X l7vl tp AtiVI
Subdivision Name: Lot#:
EXPLANATION: p CNK/yAi1(11 Z 113YWir 4_6w
4\i2 It d
Signature! Date: 3105)
Print Name: i/) �� ! C � -r- i/A /q.56
RsifundPolcy t A�y
1. The Director or Building Official may authorize the refund of 451,YL
a) any fee which was crrnncoualy paid or collected.
h) not more than 80%of the land u..w application fee when an application is withdrawn or canceled before any review effort has been expended,
c) not more than 80%of the land toe application fee for issued permits.
cl) 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 tSOM'i%of the building permit fee foe issued permits prior to any inspection requClta.
2. Refunds will be returned to the original Payer in the tame method in which payment war receive& Plrare allow 2-4 week%for prtxer%ing refund+:.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date p, /y By
Refund Processed: Dare 3/3, /y 13y. Invoice Processed: Dare By
Permit Canccicd: Date 3/J/ty By Parccl Tag Addcd: Date By
Rcccipt# Datc Method Amount$
1:\Bolling\Forma\RegPcrm IAeuon.doc Rev 05/25/2012