Permit Support Document From: 02/04/2015 09:24 #937 P.001/002
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT FEB 4 2015
CITY OF x Request for Permit Action BUILDING DIVISION
TIGARD 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
VO
Building Division �7°��`'�°
13125 SW Hall Blvd.,Tigard,OR 97223 c�a �� >r��
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @ti rd-or.gov
FROM: ❑ Owner ❑ Applicant contractor ❑ City Staff
Check(✓)one
REFUND OR Name: J/eati.n9 Fes'Coding,Line.
INVOICE TO: (Business or Individual)
750n S W Tack Centekr fir
Suite 130
Mailing Address: Tigard,OR 97223
www.speciaityheating.com
City/State/Zip: 503-620-5643
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
[✓]✓ CANCEL/VOID PERMIT APPLICATION.
lig REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
(l INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: )'tri-eG o S - (fib i °
Site Address or Parcel#: I V G 4�v ( {1 rf gib �� id 9 72_2_ s
Project Name: 0/1` c cC ) Z t11< F/
Subdivision Name: Lot#:
EXPLANATION: �U'�9�2? r -,ce l(� J U2j
Signature: Date: L,` S
Print Name: Ov't'Ark
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. /VA /2-67-17f"/
2. All refunds will be returned to the original payer in the form of a check via US postal service. Q , �a
3. Please allow 3-4 weeks for processing refund requests. /o. 0-6 - • /se,
ea . 6 y ao• /f
FOR OFFICE USE ONLY
Route to Sys Admin: Date - By Route to Records: Date Q2 .26 AS By -'""
Refund Processed: Date./- / By I# 4 Invoice Processed: Date By
Permit Canceled: Date v/(6 B)• ,iii/ arcel Tag Added: Date By
I:\Building\Forms\ResPemvtAction_0 314.
TIGARD
City of Tigard
February 26,2015
Specialty Heating&Cooling Inc.
Attn: Andrea Dripps
7500 SW Tech Center Dr., Ste. 130
Tigard, OR 97223
Re: Permit No. MEC2015-00050
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11100 SW 109th Ave.
Project Name: Flora
Job No.: N/A
Refund Method: ® Check#216604 in the amount of$80.64.
❑ Credit card "return" receipt in the amount of$
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 cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerel ,
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: Specialty Heating&Cooling Inc. DATE: 2/19/2015
Attn: Andrea Dripps
7500 SW Tech Center Dr,Ste 130 REQUESTED BY: Dianna Howse
Tigard, OR 97223
TRANSACTION INFORMATION:
Receipt#: 199206 Case#: MEC2015-00050
Date: 1/30/2015 Address/Parcel: 11100 SW 109th Ave.
Pay Method: CreditCard Project Name: Flora
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%o of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Mechanical permit fee 230-0000-43102 $72.00
12% State surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/D :E:
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 ONL
Case Refund Processed: I Date: a2//p/,� I By
L\Building\Refunds\RefundRequest.doc N 09/01/2010