Permit From: 01/26/2016 15:09 #301 P.001/003
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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1 _ Re uest for Permit Action CITAN 2 s Z
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TO: CITY OF TIGARD V
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 3 Ao !i
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@a tigard-or
FROM: 0 Owner 0 Applicant [Contractor 0 City Staff
Cheek On one
REFUND OR w c11 FtOIAO TAlil Hartin Ar/41 hsKIiifi(
Mailing Address: 1351 o 9114 Pieter(TI
city/State/Zip: Tflitroi of 1417+
Phone No.: / GI r e(4 1
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1):
:Li CANCEL/VOID PERMIT APPLICATION.
,iii REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
V INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERIVir" (do not cancel permit).
Permit#: m W w- 5
Site Address or Parcel#: al 10 9 (Iou nts im V 1 i 1441et 1'M4
Project Name: PI •h
Subdivision Name: Lot#:
EXPLANATIQN: : d ti r 1. h ', 4 L . •
ptywiif Or • to Wee Voe tit I lel, roofer-
Signature: , Date: 11141{C/
Print Name: ' 142.1156%
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund ofi
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 termed to the original payer in the form of a check via US postal servije,.�_,vO
3. Please allow 3-4 weeks for processing refund requests. %6a(TV — ?077 0- r a'. ere
Route to Sys Admin: Date By Route to Records: Date 3 -7 /G By
Refund Processed: Date 3,3//(o By Invoice Processed: Date By
Permit Canceled: Date 3./..V/4, Tag Added: Date By
L\nu�+g\Forms\RegPem,1LActioa o921/14.doc i
111
Ir - .
T I GARD
City of Tigard
March 3, 2016
Bull Mountain Mechanical
Attn: Laura Hansen
13580 SW Rhett Ct.
Tigard, OR 97224
Re: Permit No. MEC2016-00070
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9105 SW Mountain View Ln
Project Name: Petrin
Job No.: N/A
Refund Method: ® Check#220306 in the amount of$80.64.
❑ Credit card "return" receipt in the amount of$ .
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
n Trust account"deposit"receipt in the amount of$ .
Comment(s): Cancel permit per applicant's request as it was replaced by permit
MEC2016-00071. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
��T Oil
.�' /' . / , G, _
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
ErCity 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 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: Bull Mountain Mechanical DATE: 2/25/2016
13580 SW Rhett Ct
Tigard, OR 97224 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 401731 Case #: MFC2016-00070
Date: 1/28/2016 Address/Parcel: 9103 SW Mountain View Ln
Pay Method: CreditCard Project Name: Petrin
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
Mechanical Permit 230-0000-43102 $72.00
12°o State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff ' Grg(____
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: Date: ,/3//1., By:
I:\Building\Refunds\RefundReyuest.doe N 09/01/21110