Permit Support Document 09/1112014 09:02 Tice Electric Company (FAX)5038728275 P.002/004
RECEIVE,
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
-_ Request Permit Action SEP 11 2014
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r: i,„ 13125 SW Hall Blvd. •Tigard,Oregon 97223 •503.718.2439
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)iIILAIIV .DIVISION
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd,Tigard,OR 97223 VOID
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov f12//,9//y
FROM: ❑ Owner ❑ Applicant ® Contractor ❑ City Staff
(check one)
REFUND OR Name: TICE ELECTRIC COMPANY
INVOICE TO: (Business or Individual)
Mailing Address: 5405 N LAGOON AVE
City/State/Zip: PORTLAND/OR/97217
Phone No.: 503-872-8230
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
E 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#: ELC2014-00447
Site Address or Parcel#: 15252 SW ROY ROGERS RD SHERWOOD OR 97140
Project Name: BAGGENSTOS FARMS
Subdivision Name: Lot#:
EXPLANATION: WORK NOT BEING PERFORMED AT THIS LOCATION BUT
ACROSS THE STREET AT 15801 SW ROY ROGERS RD SHERWOOD OR 97140
WRONG ADDRESS WAS GIVEN FOR ACTUAL WORD.LOCATION PUTTING IT IN
WASHINGTON COUt JURISDICTION.
Signature: � ���� / / s: ►_./� Date: 9/11/2014
THERESA HOLLAN q gerliNr� i2�itrn/
Refund Policy
/9V•10 r /37.901.
01.
1. The Community Development Director or Building Official may authorize the refund of. c' '9 9 ' /6 #79 , ,
a) any fee which was euoneuusiq paid or collected, � 3 9 p
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review expend 4
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 being permit fee for issued permits prior to any inspection requests
2 All refunds will be returned to the original payer in the form of a check Please allow 3-4 weeks for processing refund requests.
I OIt O1'I'I(:I', i :;F ONL1
Rte to S a Admin: Date •a1/M1E1 11_0102 Rte to Bl•_Admin: Date/p AlErff' B ,
Refund Processed: Date /Q, By d'ij Invoice Processed: Date By
Permit Canceled: Date ,ArMi • fay"' Parcel Ts:Added: Date B
Receipt# Date Method Amount$
A
TIGARD
City of Tigard
October 13, 2014
Tice Electric
Attn: Theresa liollan
5405 N Lagoon Ave.
Portland, OR 97217
Re: Permit No. ELC2014-00447
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15252 SW Roy Rogers Rd
Project Name: Baggenstos Farm
Job No.: N/A
Refund Method: ® Check#215236 in the amount of$156.71.
❑ Credit card "return" receipt in the amount of$ .
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 job was not in Tigard jurisdiction. Refund 80%
of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
^A- -
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.*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: Tice Electric DATE: 10/2/2014
Attn: Theresa Hollan
5405 N Lagoon Ave REQUESTED BY: Dianna Howse
Portland, OR 97217
TRANSACTION INFORMATION:
Receipt#: 197204 Case#: ELC2014-00447
Date: 8/13/2014 Address/Parcel: 15252 SW Roy Rogers Rd
Pay Method: CreditCard Project Name: Baggenstos Farm
EXPLANATION: Per applicant's request as job site was on another parcel in Washington County
jurisdiction. 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 $139.92
12%State Surcharge 100-0000-24001 16.79
TOTAL REFUND: $156.71
APPROVALS: SIGNA . • DATE:
If under$5,000 Professional Staff "7(
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 ONL
Case Refund Processed: I Date: I /e/3//Y By: I
1:\Building\Refunds\RefundRec uest.doc s 09/01/2010