Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT AUG 2 6, 2014
111 'I Request Permit Action CITY OFT GARD
T1 ti A RD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503..718.2439 • ____ $ 'fl tJSf N
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 V 01
Phone; 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov �►`�� /;/ ;'
FROM: El Owner ® Applicant ❑ Contractor El City Staff
(check one)
REFUND OR Name: Squires Electric, Inc.
INVOICE TO: (business or Individual)
•
Mailing Address: 1001 SE Division St. #1
ii
City/State/Zip: Portland, OR 97202 _
Phone No.: 503-252-1609
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
® CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELC2014-00466
Site Address or Parcel #: 10185 SW Serena Way Tigard 97224
•
Project Name:
Subdivision Name: Lot#:
EXPLANATION: Our permit not needed. Contractor already has permit.
Signature: Date: 8/26/14
Andrew Cohen 2 '/
Print Name: 71,VI/ — 6,2, 75"
9, v/- 7.53
Refund .
fund Policy � �r ��
1. The Community'l)evdopmncnt Director or Building Official may authorize the refund of: 7o r
a) any fee which was erroneously paid or collected.
b) not more than 8",of the land use application fee when an application is.withdrawn or canceled before any review effort has been a tended.
c) not more than 80"s of the land use application fee for issued permits. 1
d) not more than l.O%of the building plan review fec when an application is canceled before any plan nn-new effort has been upended,
e) not more than 80%of the building permit fee For issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form oil cheek. Please allow 3-4 weeks for processing refund requests.
Rte to S s Admin: Date B r Rtc to Bid:Admin: Date i B :11/421
Refund Processed: Date 'AM/X, B' .0,7421 Invoice Processed: Date B•
Permit Canceled: Date .151.rjani B' .rte .w • Ta.Added: Date B
Recei)t# Date Met od Amount S
l:\building\For,ns\RegPcnnicActioo_0621 14.doc
TIGARD
City of Tigard
September 18, 2014
Squires Electric Inc
Attn: Andrew Cohen
1001 SE Division St. #1
Portland, OR 97202
Re: Permit No. ELC2014-00466
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10185 SW Serena Way
Project Name: Chinn
Job No.: N/A
Refund Method: ® Check#214998 in the amount of$70.28.
❑ Credit card"return" receipt in the amount of$
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 work was performed by another contractor.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
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
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: Squires Electric Inc DATE: 9/10/2014
Attn: Andrew Cohen
1001 SE Division St. #1 REQUESTED BY: Dianna Howse
Portland, OR 97202
TRANSACTION INFORMATION:
Receipt#: 197329 Case#: ELC2014-00466
Date: 8/20/2014 Address/Parcel: 10185 SW Serena Way
Pay Method: - CreditCard Project Name: Chinn
EXPLANATION: Per applicant's request as permit was taken out by another contractor. Refund 80%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 $62.75
12%State Surcharge 100-0000-24001 7.53
TOTAL REFUND: $70.28
APPROVALS: SIGNATU S/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 O Y
Case Refund Processed: I Date: I ///f/// By: I OX
1:\Building\Refunds\RefundRequest.doc x 09/01/2010