Permit To: Page 2 of 3 2015-08-18 22:40:23(GMT) 15039721861 From Charlynn Leifsen
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City of Tigard • r.OMMUNITY•DEVELOPMENT DEPARTMENT ,,~ /0 s0*
N = Request for Permit Action 406N-°: I/ii)
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Tic.;;\li 1) 13125 SW Hail Blvd. •Tigard, Oregon 97223 •503-718-2439 • v��. ' - r =o'- 8 2015
TO: CITY OF TIGARD "l r p
•Building Division AJ
13125 SW Hail Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner 'Applicant ❑ Contractor ❑ City Staff
Check(i)one
REFUND OR Name: L.
INVOICE TO: (Business Individual) jai t/ s-ei)
Pe L`Tf7 c, �nt,
Mailing Address: /67,4'41 ,c'Zi1 -'6 ,_...L /T- //
City/State/Zip: lake' G' tiee.9 iejr e '7/,�3c_-
Phone No.: / 2Y-3) 7L/L7--,24: 75
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).
_ INVOICE FOR FEES l�IJE (attach case fee schedule and provide explanation below).
ri REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: LL C.2v/.S-_A2& 1
Site Address or Parcel#: /6:669 Sio , .e_
Project Name: _Din/I/ F//ev?71."-,
Subdivision Name: J Lot#:
EXPLANATION: aysj-1i' s- OAA'. Cry-ad.._. ....
t
Signature:
a �--- Date: qi I i
Print Name: . !. .A .A 1. fen —
Refund Policy
1. The city's Community Development Director,Building Official or.City Engineer may authorize the refund of
• Any tee which was erroneously paid or collected.
• Not more than B(Wu of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended-
• No more than fit-1%of the application or permit fee for issued permits pnor to any inspection requests.
2. :lll 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. se,r 4 - 4,i/94, //, ,.?y
G.7Y- .: 3? _ /. SS
FOR OFFICE USE ONLY
Route to Sys Admin: Dare g'ur / ; . v I Ru,ur u,Records: Dare '0 / / li) ■Ar'`".
I Refund Processed: Date /0 / / [ By vt Invoice Processed: Date By
`Permit Canceled: Date /D / L i Rv •' areal Tag Added: Date _ By
1:\Building\t'nrtnx\RegPcm�itActinn_0923 . oc �Jy�
II II
.
TIGARD
City of Tigard
October 1, 2015
Johansen Electric Inc.
Attn: Charlynn Leifsen
16869 SW 65th Ave. #311
Lake Oswego, OR 97035
Re: Permit No. ELC2015-00509
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15500 SW 72nd Ave
Project Name: Trinity Flooring
Job No.: N/A
Refund Method: ® Check#218719 in the amount of$50.33.
❑ Credit card "return" receipt in the amount of$
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. Refund 80%of permit fees. Note: The enclosed
check is in the amount of$160.50 for this permit and permit ELC2015-00406.
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
City of Tigard
TIGAIZn 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 Peit 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: Johansen Electric Inc. DATE: 9/14/2015
Attn: Charlynn Leifsen
16869 SW 65th Ave. #311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORMATION:
Receipt#: 201505 Case#: ELC2015-00509
Date: 7/2/2015 Address/Parcel: 15500 SW 72nd Ave.
Pay Method: CreditCard Project Name: Trinity Flooring
EXPLANATION: Per applicant's request as customer cancelled job. 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 $44.94
12% State Surcharge 100-0000-24001 3.39
TOTAL REFUND: $50.33
APPROVALS: SIGNATURES/DATE:
If under $3,000 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 ONLY
Case Refund Processed: I Date: I /eV//S- By:
is\Building\Refunds\RefundRequestdoe x 09/01/3)10
To: Page 3 of 3 2015-08-18 22:40:23(GMT) 15039721861 From: Charlynn Leifsen
q CITY OF TIGARD ELECTRICAL PERMIT
1114!t COMMUNITY DEVELOPMENT
Permit*: ELC2015 06509
_.. Date issued: 07102/2015
T L(1A n,I? 13125 SW Hat Blvd.,Tigard OR 97223 503.718.2433 Parcel: 2S112DD00200
Jurisdiction: Tigard
Site address: 15500 SW 72ND AVE 200
Project: Trinity Flooring Subdivision: 1994-008 PARTITION PLAT Lot: 2
Project Description: Light fixture installation
Contractor: JOHANSEN ELECTRIC INC Owner: PACIFIC REALTY ASSOCIATES LP
16869 SW 65TH AVE, SUITE 311 ATTN: N PIVEN
LAKE OSWEGO,OR 97035 15350 SE SEQUOIA PKWY#300
PORTLAND.OR 97224
PHONE:
PHONE: 503-747-2503
FAX: 503-972-1881
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 07/02/2016 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 07/02/2015 $6.74
Type of Use: COM Electrical
Class of Work: ADD
Type of Const:
}
Occupancy Grp:
Total $62.92
Required Items and Reports(Conditions)
This permit is issued subject to the regulations conta ned in the Tigard Municipal Code, State of OR. Specialty Codas 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 160 days of issuance or if work ,s suspended for more tt:e 180
days. ATTENTION: Oregon law requires you to fellow the rules adopted by the Oregon Witty Notification Center. Those rules are set forth in OAR
SO2-001-0010 through OAR 952-001.0090. You may obtain a copy or the rules or direct questions to OUNC by calling 503.232.^987 or 1.800.332.2344.
issued By: Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which s not untended for sate,lease or rent.
OWNER'S SIGNATURE Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC' Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m,for the next available inspection date.
This permit card shall be kept in a conspicuous place on the lob site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
To: Page 1 of 3 2015-08-18 22:40:23(GMT) 15039721861 From: Charlynn Leifsen
FAX COVER SHEET
TO
COMPANY
FAXNUMBER 15035981960
FROM Charlynn Leifsen
DATE 2015-08-18 22:39:50 GMT
RE permit refund request
COVER MESSAGE
See attached.
Charlynn Leifsen
`Secretary/Treasurer`
Johansen Electric, Inc.
P(503) 747-2503 I F (503) 972-1861
http://www.johansenelectric.com
WWW.METROFAX.COM