Permit Support Document (5) To Page 2 of 2 2015-10-01 15 36 01 (GMT) 150397218, 1 From: Charlynn Leifsen
111.1. City of Tigard . commuNrrylw,\ F,I,c)pN.IEN1. Dr PA.RTNILNT oci
Request for Permit Action
7,11
oh, 2015
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gcl,.e.,,,a0 I„1125 StX/ 11411 Blvd. •Tigard, Oregon 97223 • 503-718-2439 • 1\2.L.Ny142M- ../b,i, .:. itth
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TO: CITY OF TIGARD
VO I D
Building Division
13125 SW I lail Blvd.,"ligard, OR 97223
Phone: 503-718-24:I9 it'ax:: 503-598-1961) "FigardBuildingPermits@rigard-or.gov 7e,4. ......5.-
FROM: D owner Li Applicant ? :Contractor Li City Staff 7 71041
REFUND OR Name: ,
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INVOICE TO: (R" 1('''." "I''''''"d1) ` //1,ie,/1 • 7)/C:
- $? ' (71:;',`) Ati i4W
Mailing Address: 1/& 47 ,.- .Li ,,t''...-- :--- ,
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City/State/Zip. /4A/Z.1
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
CAN 7 ,/VOID P 0 l APPLICATION
Li REFUND PERMIT f?r,F,S (attach copy of original receipt and provide explanation below).
F. iNvo tcr-: FOR FEES DUI', (attach case fee schedule and provide explanation below).
REMOVIVRI'n.„A.CF, CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: 1:-I-6 2r)]`-:-.) --- L74,±i f74)—
Site Address or Parcel #: 1 47375‹._:7) 5-12 '4:Se_41,coile.L. 44- -3
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Project.Name: -...-12L-L.' t.2L .1:'-i,---
Subdivision Nanie: Lot#:
EXPLANATION: rlvk.,cab cf
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Signature: Date: tk,1
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I. fne rtty's Communny Dc.,.t.11,p;net It DircLtor,Ruddin;;('litict:d or<.ity Fngtn;er tn;ly authortze the refund of:
• .lily ice wbIch o as tarrtneo.c.1:, wit)or c,,Ilccted.
• Not morn than go"0 Or C)e apply-mon or pltIn Jet.-ww tee who en applicinion is withdrawn o-canceled before a VieW effort
has been eTended
• Noi snore than 80","of CIL,application or pernm ile fur isvied pi,rni;:,i-srrn-In.01 111SI,CLi1(0 rolucsts
2 All refunds it III be rctmned to t-hc ongirrti payer:n he ft,trn ofa Oita eta I IS postal•crVIC't:
3 Plcasc allow 3-4 weeks for proce,s,ng round ret it Icsi S. 2V.6...2- --,--
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AGIMOSSURNMENVEVAVVOIMPAPPOOMENMENNEMSNAIN
Route to Sys Acimin: Date 1.,finanzawisimissimumrazumerfbAl
Reft!rki Process(d: Date /0 e, .1 Br.,,,,,, 1,,,.?,„ proc,,,s,id. Date I Be !
Pc-Iron Cancelcd• I Datc ,_cf_4.5- 1 B1, -11/4 ' -' -ccl Tqn Vide& 1)1te 1 By
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City of Tigard
October 8, 2015
Johansen Electric Inc
Attn: Charlynn Leifsen
16869 SW 65th Ave, #311
Lake Oswego, OR 97035
Re: Permit No. ELC2015-00432
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15350 SW Sequoia Pkwy
Project Name: Super Winch
Job No.: N/A
Refund Method: ® Check#218873 in the amount of$83.57.
— Credit card "return" receipt in the amount of$
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.
Sincerely,
/So. ,
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 Requeitfor 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: Johansen Electric Inc DATE: 10/1/2015
Attn. Charlvnn Leifsen
16869 SW 65th Ave, #311 REQUESTED BY: Dianna Howse
Lake Oswego, OR 97035
TRANSACTION INFORsLkTION:
Receipt#: 201090 Case #. ELC2015-00432
Date: 6/4/2015 Address/Parcel: 15350 SW Sequoia
Pay Method: CredltCard Project Name: Super`'inch
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORMATION: =
r.
Fee Description From Receipt Revenue'Account No. ; Refund
Example: Building Peinut Fee- = ..- •: . - Example: 230000043101 $Amount
Electrical Permit 220-0000-43103 $74.62
12°%o State Surcharge 100-0000 8; f2%Oc)/ 8.95
TOTAL REFUND: $83.57
APPROVALS: SIGNATURES/DATE:
/ / ``�
If under$5,000 Professional Staff j � i,r;/f�
-
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over 550,000 Local Contract Review Board
- "FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY_ • - .
Case Refund Processed: Date: ,'e//s By:
f\Building\Refunds\RefundRegucst doe 09/01/2010 '