PFI2012-00038 City of Tigard ' COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action
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13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.ti arg d_or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor V'////3 40
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fag: 503.598.1960 www.tigud-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: 2-70 -eye G 7 ti /lu L
City/State/Zip: d1Z_ 4-17 L 2-
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: rf:12,0(2-"003S
Site Address or Parcel#: 14- 2-7 Q 54AJ Q 7 AVE
Project Name: ?kR-r t TI c713
Subdivision Name: Lot#: -IS,
EXPLANATION: CSU N� 3 �� , 'b V65 fT-.
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Signature: Date: --7 /2-S-/13
Print Name:
Refund Policy
1. The Director or Building Official may authorize the refund of.-
a)
fa) 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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been upended.
c) not more than 801/6 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 Wr/o 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 OFFICE USE ONLI'
Rte to Sys Admin: Date By Rte to dmin: Date / /_3 By
Refimd
-
Refund Processed: Date IVZI B Invoice Processed: Date B
Permit Canceled: Date B Parcel Tag Added: Date B
Receipt# Date Method Amount I
1:\Building\Forms\RegPermitAetion.doc Rev 05/25/2012
i
City of Tigard
August 1,2013
Sally E. Ransdell
14270 SW 97h Ave.
Tigard, OR 97224
Re:Permit No. PFI2012-00038
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: 14270 SW.97 h Ave.
Project Name: Ransdell Partition
Job No.:
Refund: ❑ Check# in the amount of$
® Credit card"return" receipt in the amount of$3,000.00.
❑ Trust account"deposit" receipt in the amount of$
Notes: Work is complete and satisfactory. Refund 100% of customer deposit.
If you have any questions please contact me at 503.718.2430.
Sincerely,
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Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 9 www.tigard-or.gov
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City of Tigard
o0m Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the RequestforPermitAction 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: Sally E Ransdell DATE: 8/l/2013
14270 SW 97"Ave
Tigard, OR 97224 REQUESTED BY: Dianna Howse
1VIW
TRANSACTION INFORMATION:
Receipt#: 189385 Case#: PFI2012-00038
Date: 12/5/2012 Address/Parcel: 14270 SW 97th Ave.
Pay Method: CreditCard Project Name: Ransdell Partition
EXPLANATION: Work is complete and satisfactory;refund 100%of customer deposit.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Customer Deposit 100-0000-22000 $3,000.00
TOTAL REFUND: $3,000.00
APPROVALS: SIGN TURES 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 ON 4Y
Case Refund Processed: Date: /3 B
I:\Building\Refunds\RefundRequestdoc%09/01/2010