Permit City T1 • COMMUNITY DEVELOPMENT DE` 'RT r
C>< y of BardIl
w rt
Request for Permit Action /�� �� - Ij, �
'--` I I t;A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard=dtiA. x72 8 2n
fl
TO: CITY OF TIGARD U(JJ, rk , 4(°,1 >
Building Division .Mil
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-oz.gov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
Check(✓)one
REFUND OR Nais �� #� , C •
INVOICE TO: (Business or Individual) Couitets �/
Mailing Address: • ' VE V4 ift.i I I S4;
City/State/Zip: A 27:LN
Phone No.: C'4ii 2.116 2. r t 6 dot ,
PLE SE TAS ACTION FOR THE ITEM(S) CHECKED (1):
ANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation beiorv).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). •
,---•. ❑ REMOVE/REPLACE COFACTOR ON PERMIT (do not cancel permit).
•
Permit #: i`/ C 2e> lb- 0027
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot #:
EXPLANATI• : • j A CA-6C it I 'M 1� k. Aff\int'l
A ti 11 Vti./ & J. '/�...,- .�` .t! ..�. \ ►A
,e�09-c v - i- & --OO y
Signature: Gm .. Date: S J� 1c,Q
,1' b_ ,�
Print Name: 4 b_01,7
1
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 returned to the original payer in the form of a check N'ia US postal service.
3. Please allow 3-4 weeks for processing refund requests. 7/ a — J.-.G ,f,2 ^ /v
cf,-sem — 6 ,k02 = / 70
j7�-S - /S., ,90
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date y 43 /(z, By -t. r
Refund Processed: Date 'y�/3//G By ..•" Invoice Processed: Date By
Permit Canceled: Date 3/31/67 By a:y Parcel Tag Added: Date , B5
uI'\Building\Forms\RegPcrmitAcdon_ 231 dac
ry
IIIII
'. ,
TIGARD
City of Tigard
April 13, 2016
Squires Electric Inc.
Attn: Andrew Cohen
657 SE Yamhill St.
Portland, OR 97214
Re: Permit No. ELC2016-00226
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 8900 SW Burnham St.
Project Name: Burnham Business &Storage
Job No.: N/A .
Refund Method: ® Check#220689 in the amount of$63.64.
❑ Credit card"return"receipt in the amount of$ .
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): Per applicant's request as permit was resubmitted under ELC2016-00240
to change from commercial to residential project. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
,(0, 07-01-e---
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
- i
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 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: Squires Electric Inc. DATE: 3/31/2016
Attn: Andrew Cohen
657 SE Yamhill St. REQUESTED BY: Dianna Howse
Portland, OR 97214
TRANSACTION INFORMATION:
Receipt#: 402711 Case#: ELC2016-00226
Date: 3/23/2016 Address/Parcel: 8900 SW Burnham St
Pay Method: CreditCard Project Name: Burnham Business&Storage
EXPLANATION: Per applicant's request as permit was resubmitted under ELC2016-00240 to change
from commercial to residential project. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee ;= Eianiple:' 2300000-43104 $Amount
Electrical Permit Fee 220-0000-43103 $56.82
12% State Surcharge 100-0000-24001 6.82
TOTAL REFUND: $63.64
APPROVALS: SIGNATU: - /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: Date: y��7//0:, By:
1:\Building\Refunds\RefundRequest.doc x 09/01/2010