Permit 02/09/2016 04:08 5036849015 WESTERN PLUMBING INC PAGE 01/01
City of Tigard ' COMMUNITY DEVELOPMENT DEPARTNI tCEIVED
• = Request for Permit Actio
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T;1.,:A Ft.D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503 718-2439 -www,tig ,� r v2016
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BUILDING DIVISION
TO: CITY OF TIGARU
Building Division VOID
13125 SW 1-call Blvd,,Tigard.OR 97223
Phone: 503-718-2439 Fax: 503-598-1960TigardBuildingPerrnits@tigard-or.gov3/. ff 4ite_.
FROM: ❑ Owner X Applicant ❑ Contractor ❑ City Staff
Check V)One
REFUND OR Name:
INVOICE TO: (liusinesr„r individual.) -iN,5t ik\rYWD.61Cy. ) Q-,__.e_________—
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Mailing Address: 0' f li .� . -�.0. apt t�,4• . '- . , . -
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PLEASE TAKE ACTION FOR THE ITEM 14.) CHECKED (✓):
C.ANCEL/VOID PERMIT APPI.IC.A,TI(.• T.
REFUND PERMIT FEES (attach copy of riginal receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case f•e schedule and provide explanation below)_
n REMOVE/REPLACE CONTRACTOR (.1N PERMIT (do not cancel permit).
Permit 4: t1 .., , i r
Site Address or Parcel#: ; ) \ tab
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Project Name: 0 r \1. _ -
Subdivision Name: / 1 ~'4 L i . Lot 7'f:
EXPLANATION: .'A lma&r, At. ,LSA.. 'h► • t.4.1 .
Signature: hI/ �l��I •�. :.9
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Print Name: �t1 a,1,,► :I.
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I. The city's Corntnunity Development Director,Building Ofri.ial or City F.nitineer may aurhorie the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 8ON of the application or plan review e when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 8(1%of the application or permit fee ft r issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the foram<f a check via US pristal seriii- •iyuALfj
3. Please allow 3-4 weeks for processing refund requests. 90 0-0 — 702 • a–D/ a. co
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FOR (FFI&.E USE ONLY 1� � _
Route to Sys Admin: bate AM 1(s B Route to Records: Dar .ti
B'.117 Invoice Processed: Date By _
Refund Processed: Date /,. ,_ ♦ 13vPermit Canceled: Date /0/ , By 'r Parcel Tag Added: Date
l:ABuilding\Forms\Re9PcrmitAction_09..31'.d<x
III
TIGARD
City of Tigard
March 3, 2016
Western Plumbing
Attn: Dana Jensen
9460 SW Tigard St., Suite 101
Tigard, OR 97223
Re: Permit No. MEC2016-00095
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10660 SW Highland Dr
Project Name: Flrtcher
Job No.: N/A
Refund Method: ® Check#220361 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.
❑ Trust account "deposit" receipt in the amount of$ .
Comment(s): Cancel permit 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,
t ' r 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 Requestfor 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: Western Plumbing DATE: 2/25/2016
9460 SW Tigard Street, Suite 101
Tigard, OR 97223 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 401974 Case#: MEC2016-00095
Date: 2/10/2016 Address/Parcel: 10660 SW Highland Dr
Pay Method: CreditCard Project Name: Flrtcher
EXPLANATION: Per applicant's request as customer cancelled job. Refund 809i 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% State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNATURES/DATE:
If under$3,000 Professional Staffel--(4, 2/772:/ C. __
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: ��j‘„ By: Vj'27
L\Building\Refunds\RefundRequest.doc x 09/01/2010