Permit Support Document (123) 05/24/2016 15:57 5036205699 FIRESID PAGE 01/01
VOIDCity of Tigard ' COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
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 • ax: 503-598-1960 TigardBuildingPermits®tigard-ot.gov
FROM: ❑ Owner Applicant El Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) i J
Mailing Address: L b C 'Y J )O('J rn1
1Ct.�'
City/State/Zip: R3IL rq c'112
Phone No.: • _(1 J
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (f):
CEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
[7] REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: Lk-F(-4/0(�� b t)t7,,,, �,/
Site Address or Parcel#: 4 (1. S C,011-4:0 i EJ2
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Project Name: n�! �Il ` 1 1(--eiP LLi
Subdivision Name: -SfIL)A/d d (J - Lot#:
EXPLANATION: i y e4 („if- -C-U Y tr) (s (
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Signature: 4 Date: (a v"1
Print Name: 1YL V CZ {/j 1tO1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 snore 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 via US postal service.
3. Please allow 3-4 weeks for processing refund requests- ?a. , 7eP' Y /d o
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FOR OFFICE USE ONLY
Route to S s Adrnin: Date LW , B (111.) Route to Records: Date _ B .a•_
Refund Processed: Date / / By Stir xi-voice Processed: Date By
Permit Canceled: Date 5"2 fl 4 Ii s f Parcel Tag Added: _ Date By
I:\Building\Forms\RegPetmitActionJ.2314. oc
$111
-
TIGARD
City of Tigard
June 3,2016
Fireside Distributors
Attn: Erin Pennington
18389 SW Boones Ferry Rd
Portland, OR 97224
Re: Permit No. MFd016-00335
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11060 SW Cottonwood Ln
Project Name: Englewood
Job No.: N/A
Refund Method: ® Check#221188 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): Per applicant's request as the permit was pulled by mistake. 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
7Ill
City of Tigard
Accela Refund Request
TIGARD
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: Fireside Distributors DATE: 5/26/2016
Attn: Erin Pennington
18389 SW Boones Ferry Rd REQUESTED BY: Dianna Howse
Portland, OR 97224
TRANSACTION INFORMATION:
Receipt#: 403799 Case#: MEC2016-00335
Date: 5/10/2016 Address/Parcel: 11060 SW Cottonwood Ln
Pay Method: CreditCard Project Name: Englewood
EXPLANATION: Per applicant's request as the permit was pulled by mistake. Refund 80%of permit fees.
l c1]0kitOif�liil g1rom-ltecel tM h ,:72';','N-f;5'
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Example:•BuPermit Fed r :;yi 304 . 1 . i1.ii$,:::
Mechanical Permit 230-0000-43102 $72.00
12%State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIG 4„. aria S/DATE:
If under$5,000 Professional Staff � ' 1 , -
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: I Date: I ‘73/47 I By:. —
I:\Building\Refunds\RefundRequest.doc x 09/01/2010