Permit Support Document (132) City Of Tigard • COMMUNITY DIVIsLOPMINT DEPARTMI?NT REC IV
Request for Permit Action APR
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • w w.ti - ..�t
1.1
ARD
TO: CITY OF TIGARD
Building Divisiinionon
V 0 I I
13125 SW Hall Blvd.,Tigard, OR 97223 B' " AY'
Phone: 503-718-2439 Fax: 503-598-1960 Tigard uildiigPermits@tigard-or.gov
FROM: I I Owner H Applicant k/I Contractor I I City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Vaughn Environmental, Inc
Mailing Address: PO Box 879
City/State/Zip: Newberg OR 97132
Phone No.: 503.487.6687
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
7 CANCEL/VOID PERMIT APPLICATION.
n REFUND PEII\IIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
I I REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit H: PLM2016-00211
Site Address or Parcel #: 9888 SW Sattler St
Tigard, OR 97224
Subdivision Name: Alderbrook Farm Lot H: 10
EXPLANATION: I was unaware this new construction already had a backflow device.
(SEE" Aji A9/_4---0036 S"—D036 6)
Signature: /E Z1 1' z7,
Date: 4/20/2016
Print Name: Raegan Vaughn
Refund Policy
1. The city's Community Development Director,Building Official or Cite 1{ngineer may authorize the refund of:
• ;Any fee which was erroneously paid or collected.
• Not more than 80"/°of the application or plan review fcc when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80°4.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 via US postal service. /r, So
3. Please allow 3-4 weeks for processing refund requests. 707 — _S " re
7O - 6 ,9 6 -- f' 7y
6 y. 94, i6• oy
FOR OFFICE USE ONLY
Route to Sys.-Adtnin: 'to — • By Route to Records: Date 3 hb By a
Refund Processed: Date3 Bt ��, Invoice Processed: Date By
P enntt Canceled: Date /b By •.!' Parcel Tag Added: Date By
I:ABuilding\I'orns\Rall'crmit:Action )9231 doe
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TIGARD
City of Tigard
June 3, 2016
Vaughn Environmental Inc.
Attn: Raegan Vaughn
PO Box 879
Newberg, OR 97132
Re: Permit No. PLM2016-00211
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9888 SW Sattler St.
Project Name: Staehnke
Job No.: N/A
Refund Method: ® Check#221226 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 already permitted under PLM2015-
00366. Refund 80% of permit 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
111I ° 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: Vaughn Environmental, Inc. DATE: 5/26/2016
Attn: Raegan Vaughn
PO Box 879 REQUESTED BY: Dianna Howse
Newberg, OR 97132
TRANSACTION INFORMATION:
Receipt#: 403332 Case#: PLM2016-00211
Date: 4/20/2016 Address/Parcel: 9888 SW Sattler St.
Pay Method: CreditCard Project Name: Staehnke
EXPLANATION: Per applicant's request as work was already permitted under PLM2015-00366. Refund
80%of permit fees.
FII1lD INFORMATION, '' .,
Fee Desc4ikiii From Receiln -' Reve i*-WOou nt116 to ,rY,
Exaniple: 1ui1dingPermit Fee Uxar i ple 2300000-43104 ', _.'$' h :1 it
Plumbing Permit 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGNAT AT :
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 ON 1....c6c..,
Case Refund Processed: Date: 6/..7//4. By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010