Permit Support Document May. 29. 2014 10:45AM No. 4892 P. 1 brli'l�>E
RECEIVE
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request Permit Action MAY 29 2014
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • www.tigard-' PwOF TIGARD
• . DIVISION
TO: CITY OF TIGARD
V Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 7/0
24f/q
Phone: 503.718.2430 Fax: 503.598.1960 wvvw.tigard-or.gov
FROM: ❑ Owner ❑ Applicant contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO. .. . .. • - . - •
Mailing Address: (0,33/a 5 ( /0 v
City/State/Zip: Re),e ), 0,e 9-7 z ea
Phone No.: 5-63- 133 —. (o 4/(07
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
El 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).
l REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: gLC Zp/y— d p Z$
Site Address or Parcel#: y/D c5 Lc) 6 9 5�'t
Project Name: `,IDc U z./q--s
Subdivision Name. Lot#:
EXPLANATION: Cc,.),P6'r7 /7-7/ - 0 / D
S ez-- a-oi 9 -OC
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Signature: 1 , // - _41.40 Date: `�/2�/
Print Name. , e (5/6.0-7.5e
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Rsfund Policy V (r ` /0•bP /
I, The Director or Building Official may authorize the refund of: �-
a) any fee which was erroneously paid or collected- '7,, , 3 <— P,5 V 79. 7 7
b) nor more than 80%of the land use application fee when an application it withdrawn or canceled before any review effort has been expended.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 fee 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 receired. Please allow 2-1 weeks for processing refunds.
FOR OFFICE 1'ti1-; ONLY
Rte to S s Admin: Date B Rte to B1d:Admin: Date _7/// B 1:
Refund Processed: Date 7 tvMI B. �iI7 Invoice Processed: Date
Permit Canceled: Date 7Maria B y eArGag •arcclTa:Added: Date B.
Recci.t# Date Method Amount$
I:\Building\Dorms\RegPermiulction.doc Rev 05/25/2012
,7 n
1
Ti GARB
City of Tigard
July 31, 2014
Red's Electric Co. Inc.
6336 SE 107th Ave.
Portland, OR 97266
Re: Permit No. ELC2014-00284
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9410 SW 69th Ave.
Project Name: Douglas
Job No.: N/A
Refund Method: ® Check#214527 in the amount of$79.77.
❑ Credit card"return" receipt in the amount of$ .
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$ .
Comment(s): Per applicant's request as permit was for wrong scope of work and was
resubmitted under ELC2014-00285. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
01.4),..., , tsje______
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
• 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: Red's Electric Co. Inc. DATE: 7/24/2014
6336 SE 107th Ave.
Portland, OR 97266 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 196204 Case#: ELC2014-00284
Date: 5/27/2014 Address/Parcel: 9410 SW 69th Ave.
Pay Method: CreditCard Project Name: Douglas
EXPLANATION: Per applicant's request as permit was for wrong scope of work;resubmitted under
ELC201-4-00285. Refund 80%a of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Electrical Permit 220-0000-43103 $71.23
12% State Surcharge 100-0000-24001 8.54
TOTAL REFUND: $79.77
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff 7/2 9
IE 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 Y„ . ,
Case Refund Processed: Date: -7////y By:
I:\Buil ding\Refunds\RefundRequest.doc x 09/01/2010