PFI2015-00112 a
City of Tigard
December 10, 2015
Polygon WLH LLC
Attn: Chris Walther
- 109 E 13`h Street
Vancouver,WA 98660
Re: Permit No. PFI2015-00112
Dear Applicant:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address:
Project Name: River Terrace Northwest
Job No.: N/A
Refund: ® Check#219502 in the amount of$254,675.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account"deposit" receipt in the amount of$
Notes: Refund of deposits for erosion control $64,600.00 and grading only $190,075.00.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. 0 Tigard, Oregon 97223 0 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
Ink F It
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 Requej-tforPemzit Actiaft 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 Nveeks for processing of refunds. _accounts
Payable will route refund checks to Accela System_administrator for distribution to applicant.
PAYABLE TO: Polygon %Y/LH LLC DATE: 12/7/?015
Attn: Chris Walther
109 E 13"' St REQUESTED BY: Dianna Howse
Vancouver, WA 98660 �1ti�7
TRANSACTION INFORMATION:
Receipt#: 202432 Case#: PFI2015-00112
Date: 9/2/2013 Address/Parcel:
Pay Method: Check Project Name: River Terrace Northwest
EXPLANATION: Refund of erosion control 56+,600.00 and grading only deposit$190,075.00.
.REFUNDINEORiti1t1TION
Fee'•DescriptlonTrom Receipt Revenue Account No �i i Refund
Ezain le 'tBull'duii Permit Fee r _ Esarn le .;230000.0 1310 ,,,. Amount
n.Customer Deposit 100-0000-23000 523=1,673.00
TOTAL REFUND: $25=1,675.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$23,500 Department Manager
If under$30,000 City Manager
If over$50,000 Local Contract Review Board
:r.EOR TIDEMARK SYSTEM_ADMINISTRATION-USE_ONLY
Case Refund Processed: Date: /a / /s By:
I:\Building\Refunds\RefundRequest.doe s 09/01/3010
City of Tigard • COn[nIUNi'l'l' lll.\'I:LOPntI.N"1' DI.P:\R'1'niRN'1'
Request for Permit Action
13125 SW Hall Bh-d. • Tigard, Orcgon 97223 • 503-718-2439 • \x-wvv.tigard
TO: CITY OF TIGARD
Building Division
13125 SVG Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuddingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: 10 q 12-
City/State/Zip:
3City/State/Zip: V*--) q7 U noL- ✓A , �g 64, O
RfA%W dAt4 4"194 S "A0* M0o.„
r, + Phone No.: $a 3 - 712- - 2.113
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#: FF! 2,0(5, - Of1 lt Z
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: RF-FJt-p or- 94Or&-) ce�—Tga- I teas fT A7--:"t> aA4-0/#z(1-
av I koS(-r-. 6 4. 6 00.- 1 10A 07 S, 5- -= 2s4. 6 Tr*
�I Zoe 432 ATrA-e-Ha
Signature: Date:
Print Name: /►�/�(� ltiH !T�
Refund Policy
1. The city's Community Development Director,Building;Official or City Fng;ineer may authorize the refund of:
• :\nv fee which was erroneously paid or collected.
• Not more than 801/o 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 paver in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to tips Admin: DateBy Route to Records: Date B
Refund Processed: Date � /e / Invoice Processed: Date B
Permit Canceled: Date /(/ By 'arcel Tag added: Date By
1:\Building\Forts\ltcy Permit\criun_09n 14 d�,c