Inspections Oct. 26. 2015 9: 01AM No. V O 1 I
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT fQ/f 44
= Re q uest Permit Action EIVEP •
T? ,Aft ry 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard ,gov
TO: CITY OF TIGARD t-Ti U
Building Division Services Supervisor B�IL JIG
lNU
13125 SW Hall Bh d.,Tigard,OR. 97223
DING��Ut A
• Phone 503.718.2430 Fax: 503.598.1960 www.rigard-or.gov
•
FROM: [❑ Owner ❑ Applicant Contractor ❑ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: ' gQ 5 t S (
City/State/zip: Gael e_,( f
Phone No.: (]3 cfcel 124-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ 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#: lrz_g'-Ao!?- 00 2-54
.. l
Site Address or Parcel#: I"2 0 `j 5L`J P c. t \ �
Project Name: 5 u 1000( trL ,e PG
Subdivision Name: l Lot#:
EXPLANATION; t. P\ .' L Ilb. : • 15— 66)2')(-4
Signature: ` te„`- ' t Date: eel2a(ts
Print Name: err 1r\C y`(\LL✓esN.
7$ c'D — G o , o-v
Refund Policy g,0-p . 7 o.a - f• Fo
1. The Director or Building Official may authoriac the refund of: !_ �
a) any fee which was erroneously paid or collected. J2`'.0-0 4 7.Ao /6
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior CO any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received Please allow 2-4 weeks for processing refunds.
R-01 FJCH; USE; uNI, .
Rte to Sys Admin: Date LA B• Rte to Bid; Admire: Date //427443. B. .%�Ir
Refund Processed: Date// ,'y $ By s,6A Invoice Processed: Date B�
Permit Canceled: Date u//fith By -4rAl. Parcel Tag Added; Date By
Receipt# Date Method Amount$
1.\Building\Forms\RegPerrniv\cdon.doc Rev 05/25/2012
ill _-
8'4t1
.GARD4
City of Tigard
November 19, 2015
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr.
Beaverton, OR 97008
Re: Permit No. ELR2015-00254
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12047 SW Pacific Hwy
Project Name: Subaru Repair
Job No.: N/A
Refund Method: ® Check#219177 in the amount of$67.20.
❑ Credit card "return" receipt in the amount of$ .
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 this was a duplicate permit (see ELR2015-
00224). Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4 '�), r ''
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_lb,-Perm it 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: ADT LLC DATE: 11/06/2015
Attn: Lori McMurphy
7989 SW Cirrus Dr. REQUESTED BY: Dianna Howse
Beaverton, OR 97068
TRANSACTION INFORMATION:
Receipt#: 400238 Case#: ELR2015-00254
Date: 10/22/2015 Address/Parcel: 12047 SW Pacific Hwy
Pay Method: CreditCard Project Name: Subaru Repair
EXPLANATION: Per applicant's request as was duplicate permit (see ELR2015-00224). Refund 80% of
permit fees.
REFUND' - ti•.Y _
Fee Description From Receipt '` Revenue Ac'coumt No 'Refund`~'
rExairiple: 230000043104 .FlAmount
Electrical permit fees 220-0000-43103 $60.00
12% State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGNATURES/DATE:
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
'. "9=Y,F''_ '=l.l, FOR TIDEMARK'SYSTEM,ADMINISTRATION USE ON
Case Refund Processed: Date: jj /jam/lf By: qj ,
1:\Building\Refunds\RefundRequest.doc x 09/01/2010