Permit FROM MP Plumbing (WEDWAN 6 2016 14:55/ST. 14:54/No.9309294496 PI 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEI •x{/1LP
Request for Permit Action JAN 6 2016
13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.ti tar -or.e7yl
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TO: CITY OFITGARD � � 1N(�DIV ^ R
Building Division
13125 SW HaD Blvd.,'1'igard OIL 97223 / Z/�/�p
Phonc 503-71&2439 Fax: 503-59&1960 Tig BwldmgPemtitaQtigard god
FROM: ❑ Owner ❑ Applicant ® Contractor ❑ City Staff
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REFUND OR Name:
INVOICE TO: (Bu,inm 1rvJivdtu9 rn� '3& \n
Mailing Address: � a�C
City/State/Zip: S�'LU�b(�S nr5, 97n i
Phone No.: C11�j-(p�C- gII,OI
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED
[CANCEL/VOID PEPMITAPPLICATION.
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#: PL �m 21)6- n2 Z,2-
Site
ZSite Address or Parcel #: M`62)
Project Name: 3�8 n?)( Cg `�4J
Subdivision Name: Lot#:
EXPLANATION: 0
Signature: Ohio H ONW6== Date: 1
Print Name:
e
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1. The eiN's Contntunity Ikvelopment Director,Buikling Offi ial.e Ciry P.ngineer nnay authorize the refurxl of.
• Any fee which was ertnnenuciy paid or collected.
• Not more than Wle of the application or plan review fee whc,,a,,application is withdrawn or canceled before review effort
has been expended.
• Not marc than BO%of the application or permit fee for issued prmdts prior to any iuspemton reyucvq.
2. All reftmds will he returned to the original payer in the fomn of a check via US postal service.
3. Pimse allow 34 weeks for po:lco mg refund rcqucsm %2. � — „S/�'r C-0 = /Yi SCSI
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p/.
Route to Sys Admin: Date By Route to Records: Date / B
Refund Processed: Dare /12� /(u B Invoice Processed: lhte B
Pcnrdt Canceled: Date / �j / B =el Ta Added: Date e
1:\Building\Forms\RegP.a i,Aai,m_l 211 .Joe
■
City of Tigard
January 21, 2016
MP Plumbing Co.
Attn: Donna Matthews
PO Box 393
Clackamas, OR 97015
Re: Permit No. PLM2015-00222
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11383 SW Palm PI
Project Name: Sagers
Job No.: N/A
Refund Method: ® Check#219872 in the amount of$64.96.
❑ Credit card"return" receipt in the amount of$
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): Pet 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,
44��r-rz-
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of 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: NIP Plumbing Co. DATE: 1/14/2016
Attn: donna Matthews
PO Box '93 REQUESTED BY: Dianna Howse
Clackamas, OR 97015
TRANSACTION INFORMATION:
Receipt#: 201671 Case #: PLM2015-00222
Date: 7/16/2015 address/Parcel 11383 SWPalm P1
Paybtethod: CreditCard Project Name: Sagers
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
REFUND INFORbIATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit 230-0000-43101 $58.00
12% States Surcharge 100-0000-24001 6.96
TOTAL REFUND: U4.96
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
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: I Date: 1 117-1 / B
C\Building\Refunds\RefundRequest-dot z 09/01/2010