Permit Mar 21 16 01:43p Clog Busters LLC 5035308494 p.1
RECEIVED
City of Tigard • COA:M .:N 1Y DEvlt1.ohkfr�.N"1'1Df:PAR'1ltII,IQ'f 21 2016
11111 CITY OF rARD
. Request for Permit Action BUILDING �+
TIGARD
13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • \\.,v, -c.1-c.)1 )v ��N
TO: CITY OF TIGARD
V0
Building Division •••���
13125 SW Hall Blvd.,Tigard,OR 97223 ,rj Y//i
Phone: 503-718-2439 Fax: 503-598-1960 TigaxdBuddingPertnits@tit ard-or.gg6v
FROM: E Owner J Applicant Wi Contractor ❑ City Staff
check!✓1 one
REFUND OR Name:
INVOICE TO: (1'usiecssorIttdivicu.A Clog Busters LLC
Mailing Address: 2900 SW Cornelius Pass Road #549
City/State/Zip: Hillsboro, OR 97123
Phone No.: 503-680-8947
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
;.� Gil REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
U INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: PLM2016-00142
Site Address or Parcel#: 6710 SW Pine St, Tigard, OR 97223
Project Name: t 9-Vj,(/4/
Subdivision Name: Lot#:
EXPLANATION: Customer had repair completed by another contractor and we will
no longer be doing the work
_
Signature: Date: 3/21/2016
Print Name: Patricia Wolfe
jtefund Policy
I. 'I1':c city's Con;munitc Development Director,Building Official or City Ifnginccr may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 81%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not inure than 8110'o of the application nr permit tcc for issued permits print to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check ti•a US postal • /�
3. Please allow 3-4 weeks fur processing refund request,. �� /q. .5
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0 64/, 16 /b.ay
FOR OFFICE USE ONLY
Roure to Sys admin: Date Be Route to Records: Date ee 2. /(o By ,0 4.
Refund Processed: Date y72, /6,1 By V ' Invoice Processed: Date By
Permit Canceled: Date e(3 /rp j By#A1/1---, Parcel Tag Added: Date By
l:AliuddIng\Purer'\itegPermit:�ction_O 731'.di,c
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111111 '
TIGARD
City of Tigard
April 28, 2016
Clog Busters LLC
Attn: Patricia Wolfe
2900 SW Cornelius Pass Rd., #549
Hillsboro, OR 97123
Re: Permit No. PLM2016-00142
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 6710 SW Pine St
Project Name: Hathaway
Job No.: N/A
Refund Method: ® Check#220645 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): Per applicant's request as work was completed by another contractor.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
'd2. 1E)r?2"-fX/-C---
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon Ore on 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 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: Clog Busters LLC DATE: 3/31/2016
Attn: Patricia Wolfe
2900 SW Cornelius Pass Rd, #549 REQUESTED BY: Dianna Howse
Hillsboro, OR 97123
TRANSACTION INFORMATION:
Receipt#: 402585 Case#: PLM2016-00142
Date: 3/16/2016 Address/Parcel: 6710 SW Pine St
Pay Method: CreditCard Project Name: Hathaway
EXPLANATION: Per applicant's request as work was completed by another contractor. Refund 80%of
permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No: Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Plumbing Permit Fee 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGN: }RES/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/?-6//a, By: i
L\Building\Refunds\RefundRequest.doc x 09/01/2010