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Permit RECEIVED City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 14 2015 11111 l;1TY(!F 1'I(;AkU _ Request for Permit Action 11IL VOf DIVISION TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tlgara-or.gov TO: CITY OF TIGARD V 1 Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 6 e ,$ 44 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov FROM: ❑ Owner ❑ Applicant ' Contractor ❑ City Staff Check(l)one REFUND OR Name: aw‘,... ei.,.,cA,e,,,t, INVOICE TO: (Business or individual) Mailing Address: i \ 5w CI)\u \ ho, tfj,(j(t City/State/Zip: W 1 M l a.._ 617 020 1 Phone No.: M?) -- LA O' - `?34 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ri 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#: oZQ/s-Vol o7 s Site Address or Parcel#: 13$a,U u OT h ?y,NAji 5 l7 Project Name: ' O QAK:3 /672. Set 2 Subdivision Name: Lot#: EXPLANATION: b , ' c-' - /�L.C',,2a/S_.-io3s 1 - Signature: II.L. 'l' 'a,....--- Date: 5/43.- Print Name: -' _1.1lb. 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. S. CI) — (oOC / , oZ) 7, ere — '9 atd --i eo ,„ , A.0 /4.ke = 6F y. ez.) colt OFFICE LSE ONLY Route to Sys Admin: Date By Route to Records: Date(; If S By 1 - Refund Processed: Date i,7/5 By .j. , • uicc Processed: Date By Permit Canceled: Date.//r/A B if' Parcel Tag Added: Date _ By 1:\Budding\Forms\ResPermitAction_09231 .doc ,' " TIGARD City of Tigard June 18, 2015 Christenson Electric Attn: Suzi Flowers 111 SW Columbia, Ste 480 Portland, OR 97201 Re: Permit No. ELR2015-00125 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 13190 SW 68th Pkwy Project Name: Infocus Job No.: N/A Refund Method: ® Check#217585 in the amount of$67.20. n Credit card "return" receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. n Trust account "deposit" receipt in the amount of$ Comment(s): Per applicant's request as this was a duplicate permit (see ELC2015- 00356). 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 PrCity of Tigard TIGARD Accela Refund Request CD This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the ReqEestjbr 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: Christenson Electric DATE: 6/4/2015 Attn: Suzi Flowers 111 SW Columbia, Ste 480 REQUESTED BY: Dianna Howse • Portland, OR 97201 TRANSACTION INFORMATION: Receipt#: 200657 Case#: ELR2015-00125 Date: 5/8/2015 Address/Parcel: 13190 SW 68th Pkwy Pay Method: CreditCard Project Name: Infocus EXPLANATION: Per applicant's request as permit was a duplicate(see ELC2015-00356). 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 Fee 220-0000-43103 $60.00 12%State Surcharge 100-0000-24001 7.20 TOTAL REFUND: $67.20 APPROVALS: SIGN. - 'ES/DATE: If under$5,000 Professional Staff 1., 47 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 ON Y Case Refund Processed: I Date: I OA„IpS I By: 1:\Building\Refunds\RefundRequest.doc x 09/01/2010