Permit Support Document (159) City of Tigard • COMMUNITY DEVELOPMENT DEPARTIIEN'I�
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Request for Permit Action �' /�
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-I-1(,A R I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner -\pplicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) G4-fe,,, �i� --7_,E-e7-72i-e.„, eii/t.s/9/AJ 7-e,J LL e--
Mailing
MMailing Address: 4/0.2 V.4-z7 e9-/E-- A// ) S7 /0<o
City/State/Zip: it)te•-)l f}-L 4-C ,/°/ 'A)4FpeS 7/
Phone No.: , 25--..3 f z2 r 6 05/
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 1
VCANCEL/VOID PERMIT APPLICATION.
EKREFUND PERMTI'FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: -z_c .,. 0/L — 00 L//0
Site Address or Parcel #: / 7902 _CA.2 /5 r /9-17E-
Subdivision Name: /904160A/ , 7 BC-LG. /7QGf 717 Al Lot #:
EXPLANATION: COArt72s4-e-ro/L /a/,t[-&&Z /4)&72-/w7- p vL/n/6- /n/
X2202 •.V .2 d LeS` ---#0,"50 . :' •
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Signature: Date:
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Print Name: ,/I(age A C f a jewSJLI
Refund Policy
I. '1'he city's(:ommunity Development Director,Building()fticial or(;itc I.ngineer may authorize the refund of:
• .Any fee which was erroneously paid or collected.
• Not more than 80°-o of the application or plan review fee when an application is withdrawn or canceled before review effort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 pacer in the form of a check via VS postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date By Route to Records: Date 073/j4„ By
Refund Processed: _ Date �p „3/f By .�-. Invoice Processed: Date By
Permit Canceled: Date_"'-�/�p By ;I• Parcel Tag Added: Date By
I:ABuilding\Forms\RegPennit-Action_ 9231 doe
11111 ".1
TIGARD
City of Tigard
June 3, 2016
Garner Electric Washington LLCq
Attn: Cara Vicarel
402 Valley Ave NW, Suite 106
Puyallup,WA 98371
Re: Permit No. ELC2016-00410
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 15192 SW 154th Ave
Project Name: Polygon at Bull Mountain,Lot 59
Job No.: N/A
Refund Method: ® Check#221192 in the amount of$112.78.
❑ Credit card "return"receipt in the amount of$
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 contractor pulled permit online, but all work is
being performed under MST2015-00250. Refund 100% of perrmit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
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
114 City of Tigard
T I G A R D 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: Garner Electric Washington LLC DATE: 5/26/2016
Attn: Cara Vicarel
402 Valley Ave NW, Suite 106 REQUESTED BY: Dianna Howse
Puyallup,WA 98371
TRANSACTION INFORMATION:
Receipt#: 403995 Case#: ELC2016-00410
Date: 5/19/2016 Address/Parcel: 15192 SW 154th Ave
Pay Method: CreditCard Project Name: Polygon at Bull Mountain,Lot
59
EXPLANATION: Per applicant's request as contractor pulled electrical permit online,but all work is being
performed under MST2015-00250. Refund 100%of permit fees.
ND IFO.RMATION
1 e'Descti iifot1 From Receipt'`- , 'Revenueyk,ecoudtNo ''':;A:,;:,:,''d
wig` Building.Pe'mit.Fee '" , a i iple:,230Q00043104 ,:!1$-!1414.,,,'rI i r.'
Electrical Permit 220-0000-43103 $100.70
12%State Surcharge 100-0000-24001 12.08
TOTAL REFUND: $112.78
APPROVALS: SIGNATURES/D TE:
If under$5,000 Professional Staff "4(2
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//(o By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010