Permit 02/24/2014 13:03 5036849015 WESTERN PLUMBING INC PAGE 01/02
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 3/3//r/ i'"� v)
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Request Permit Action at'31
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TO: CITY OF TIGARD FEB 2 4 2014
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 CITY Of. [IGARD
Phone: 503.718.2430 Fax: 503.598.1960 avww.tigard-or.gov !uP F11rt1 e1llly'!oN
FROM: ❑ Owner 15Q Applicant N Contractor ❑ City Staff
,check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) siet.. x`n .1,...E . V\Q s
Mailing Address: • , k 4'1 A *`■\ •.■*.
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C 1 ity/State/Zip: iy G OIQ )l
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Phone No.: -1 - 1c !
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
!t CANCEL/VOID PERMIT APPLICATION.
rt REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CON I RACTOR ON PERMIT (do not cancel permit).
Permit#: Q( 6D1 (_
Site Address or Parcel#: 1\� q A S j L4- nikp. 1( l
Project Name: coodko o QD __________
Subdivision Name: Lot#:
EXPLANATION: t 46, CUQ164_, kg` ( 1(... LLAs n4k
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Signature: ��. .►•/ J� t►Ii . ll Date: 6901I`7 -
Print Nam e.: . _ ...i, . 4, . 'DD. . 2EFuA./o 5-k,a) /LFr aV /d/So
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ltrfund Policy ,9
1. The Director or Building Offoal may authorize the refund s>f' G V, 9(p / y
a) any fcc which was erroneously paid ox collected.
b) not more than 80%of the land ucc application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than l O e of the land use application fcc for issued permits.
d) not more than 80%of the building plan review fcc when an application is canceled before any plan review effort has been ecpcnded.
e) not more than 80%of the building perrrnt 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 2.4 weeks for processing refunds.
FOR OFFICE t'SF ONO/.
Rte to Sys Admin; Date ;INEMBill Rte to Bldg Admin: Date 3p/ • B t irA
Refund Processed: Date i,nil B ,0 Invoice Processed: Date Br
Permit Canceled: Date 3 sa k'arcel Tag Added: Date B-
Receipt 4 Date Method Amount$
f:\Building\forms\RegPennitAction.doc Rev 05/25/2012
ErCity 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 forPermit 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: Western Plumbing Inc. DATE: 3/31/2014
Attn: Dana Jensen
9460 SW Tigard St., Ste. 101 REQUESTED BY: Dianna Howse
Tigard, OR 97223
TRANSACTION INFORMATION:
Receipt#: 194926 Case#: PLM2O14-00047
Date: 2/19/2014 Address/Parcel: 11600 SW 91st Ave.
Pay Method: CreditCard Project Name: Bell
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:
If under$5,000 Professional Staff
."Ct
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: 3/3//y By: I
1:\Building\Refunds\RefundRequest.doc x 09/01/2010