Permit Support Document Eri
n
TIGARD
City of Tigard
December 4, 2014
Lewis Landscape Services
Attn: Sheila Rosenberg
1915 NW Amerglen Pkwy, Ste 400
Beaverton, OR 97006
Re: Permit No. PLM2014-00353
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12272 SW Hollow Ln
Project Name: Scott
Job No.: N/A
Refund Method: ® Check #215776 in the amount of$71.92.
❑ Credit card "return" receipt in the amount of$ .
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 to cancel permit for the wrong site address.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/(..(2,. /--%---A..)-7-e..._
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 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: Lewis Landscape Services DATE: 11/20/2014
Attn: Sheila Rosenberg
1915 NW Amberglen Pkw,Ste 400 REQUESTED BY: Dianna Howse
Beaverton, OR 97006
TRANSACTION INFORMATION:
Receipt#: 198223 Case#: PLM2O1=1-00353
Date: 10/30/2014 Address/Parcel: 12272 SW Hollow Ln
Pay Method: CreditCard Project Name: Scott
EXPLANATION: Per applicant's request as submitted for wrong customer/site address. Refund 80% of
permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue A ccount No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing permit fee 230-0000-43101 $64.96
12% State surcharge 100-0000-24001 6.96
TOTAL REFUND: ,)
APPROVALS: SIGNATU' S/DATE:
If under$3,000 Professional Staff U~`� /j/4//r
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$30,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONL
Case Refund Processed: I Date: /�/y//V I By: I_
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
11-19-14; 12:28 ;From:Lewis Landscape Service To: 15035981960 ;5032135 CEIVtp 2
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT NOV 1 9Q4 I tJ
lig Request Permit Action CITY OF T1(;ARD/°2/" 1r
T 1 G n R D 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • wwRi I 1VISION
TO: CITY OF TIGARD
4fr rt.,1
Building Division Services Supervisor 6-1/\---
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ® Contractor El City Staff
(check one)
REFUND OR Name: Lewis Landscape Services
INVOICE TO: (Business or Individual)
Mailing Address: 1915 NW Amberglcn Parkway,Suite 400
City/State/Zip: Beaverton, OR 97006
Phone No.: 503-524-3679
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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: PLM2014-00353
Site Address or Parcel#: 12272 SW Hollow Ln.,Portland,OR 97223
Project Name:
Subdivision Name: Lot#:
EXPLANATION: Submitted for Permit under wrong name and city
Actual customer is Bill ce4,ti'
Bill Scott-394 NW 170`'Dr.,,B-.,vert•n,OR 97006
Signature: a , �, 10 . Date: 11/19/14
•eila Rosenberg • j� A/'\ '/V
la'fland Pnlir., 2�. So — _, , _ / 5O
1. The Community Development Director or Building Official may authorize the refund of P. 70 — 4 r R'Co -
a) any fee which was ermneously paid or collected. /�, /
b) not more than 80%of the land use application fee when an application is withdrawn or ca i .. ny reviewf effort `been c rnaed.r
c) not more than 80%of the land use application fig:for issued permits. elark 7 La . (ca /, 7 d) not more than 80%of the building plan review fee when an application ix canceled• w effort_.•.•rR rt
c) not more than 80%of the building permit fee for issued permits prior to any inspect, / (y„,.._ if, 6-0
2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing r, nd rC a (;t
FOR OFFICE USE ONLY /Z/VALi
Rtc to Sys Admin: Date/1 If Of By , . • Rtc to Bldg Admin: Datc/a-/y//y By iJ •
Refund Processed: Date 42/y/i/ By ri Invoice Processed: Date By d'/•02(7
Permit Canceled: Date /j�g//y By ,=, Parcel Tag Added: Date , By -- 7/r jca-
Receipt# Date Method Amount$ ' fi
!:\Building\Forms\RcgPm /
emitAction_062G14.doc ` -A l 417
__
ITO v �
x . 96 _
11-19-14; 12:28 ;From:Lewis Landscape Service To: 15035981960 ;5032135921 # 2/ 2
PLUMBING PERMIT
CITY OF TIGARD
-
q Permit ft: PLM2014-00353
COMMUNITY DEVELOPMENT /7 Date Issued: 10/30/2014
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.715,2439 Parcel: 2S143C$07700
Jurisdiction: Tigard
Site address: 12272 SW HOLLOW LN
Project: 6ackflow-Scott Subdivision: QUAIL HOLLOW-EAST Lot: 26
Project Description: Install a backflow device for an irrigation system.
Owner: SCOTT,WILLIAM JEFFREY JR
Contractor: LEWIS LANDSCAPE SERVICES, NC. N
L
1915 NW AMBERGLEN PKWY PORTLAND, OR 12272 SW HOLLOW W L 97223
BEAVERTON,OR 97006
PHONE:
PHONE: 503-524-3679
FAX: 503-213-5921
FEES
Quantity Description — Date Amount
1 ea Backflow Preventer 10/3012014 $31.27
1 12%State Surcharge- 10130/2014 $8.70
S ° Plumbing
41 ea Minimum Fee Adjustment- 10/3012014 $41.23
Type of Uso: SF Plumbing
Class of Work: ADD
Type of Const:
Occupancy Grp: �'�j �V` a
Stories: 1.p\a V . �.\.. �
774 -6\. ...-*, 1/5 :
' / \,, '•ev .. ,---.,y-kc _.(),( V .,.
.\2`c 6\11W ." % ',//,''
‘./ r -C/ Total $81.20
r
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules les adopted by the h
Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001.0010 through OAR 952.001-0090. You may obtain a copy of
direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344.
Pcrmittec Signature:
Issued 13y;