Correspondence 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: Columbia Heating& Cooling DATE: 3/31/2014
Attn: Karen Gladden
PO Box 230397 REQUESTED BY: Dianna Howse
Tigard, OR 97281
TRANSACTION INFORMATION:
Receipt#: 194874 Case#: MEC2014-00060
Date: 2/17/2014 Address/Parcel: 8995 SW Center St.
Pay Method: CreditCard Project Name: O'Neal
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
Mechanical permit 230-0000-43102 $72.00
12% State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If 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: j`F/p j By: .�
I:\Bull ding\Refunds\RefundRequest.doc x 09/01/2010
02/19/2014 11:15AM 5035980270 COLUMBIA HEATING PAGE 01/01
v , 1 •City of Tigard • COMMUNITY DEVELOPMENT DEPA TM ENT ✓,J
II 2 Request Permit Action �j 4
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T;C,;\[P.�, 13125 SW Hall Blvd. •Tigard, Oregon 97223 •• 503.718.2439 ••www.ti� �gr.gov
TO: CITY OF TIGARD kip F
Building Division Services Supervisor L�//VC I'CgRo
13125 SW Hall Blvd.,Tigard,OR 97223 vjs'JO
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov 4/
FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (8usines5'Individual) /z n 6 GL. Heeit'<is" 4 Ce /1" g
Mailing Address: Po /3 EX' 3 0 39 -7
City/State/Zip: /f c ti d , OR Z7 t7 21 l
Phone No.: 503 - (a. V= c2 70Cf -
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
Z CANCEL/VOID PERMIT APPLICATION.
El REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#_ i'ilg G a b/q -4 c O la
Site Address or Parcel#: gc??S S °�'! r-
—
Project Name: ( IV& J —
Subdivision Name: /11 J Lot#: ii t tY
EXPLANATION: I ` •a , 10ctS Ccf rxc_ /t J A O L'-e•
&r- p --f-3-1.,i-44--
Signature: Date: ) --/9 -- ‘.2O/G f
Print Name: /Car -,1 C;letdd erg ,erGuN 7P2.C1-0 2 1 '.civ
e.6,y 02. r6
$pfiind Pnliry
1. The Director or Building Official may authorise the refund of: FC ,(o V
a) any fee which was erroneously paid or collected. °24 ' /(O
1r) not more than 80%of the land use application Eco when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits
d) not more than 80%of the building plan review fce when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFF-)CF USE ONLY
Rte to 5 s Admin: Date ,gA E PA Rte to Bid:Admin: Date .3 APIPMITMIT
Refund Processed! Date 3 AM= B .;!■ Invoice Processed: Date B
Permit Canceled: Date B .;.. Parcel Ta:Added: Date B .
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAcriondoc Rev 05/25/2012