Permit Support Document (169) Apr. 29. 2016 1 : 10PM • No. 3328 P. 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V ,' 1 J
Request Permit ActionZb �,� 44/
•
r;,;A;.fl) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • rww.tiigars !,47
6
TO: CITY OF TIGARD + ti ` �� •
Building Division Services Supervisor '%;,r'l ' I
13125 SW Hall Blvd.,Tigard,OR 97223 -!(-.)try
"V
. . • Phone: 503.718.2430 Fax; 503.598,1960 www.tigard-or:gov •
FROM: ❑ Ownet ® Applicant ❑ Contractor n City Staff
(check one)
REFUND OR Name: ADT LLC
INVOICE TO: (eusiness or lndh dual)
Mailing Address: 7989 SW Cirrus DR
City/State/Zip: Beaverton, OR 97008
Phone No.: 503-469-7241
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
® REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: FI 82015-00279
Sire Address of Parcel#: 9445 SW Locust St
Project Name: Tigard Orthopedic Fracture
Subdivision Name: Lehmann Acre Tract Lot#: 3
EXPLANATION: Customer cancelled install
Signature: 1 t`'Y Date: 4/29/16
Lori McMurphy v i
Print Name: y
2j
Refund Policy I 6o .CV - /5- 4-6
I. The Director or Building Official may authorize the refund of: 9'•Lam _
a) any feu which was erroneously paid or collected. A/�41�r �j7,
b) not mote than 80%of the land use application fee when an application is'chc yawn ocanceled before y review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80°/n of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) nor more than 80%of the buildingpermit fee for issued permits prior to any inspection requests.
2. Refunds will be returned co the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
I'OR OFFICE UST-ONLY
Rte to Sys Admin: Date 5 zo Byll.. Rtc to Bldg Admin: Date op/3 /6 By Sye-
Refund Processed: Date(o/ , By . _` Invoice Processed: Date By
Permit Canceled' _Date /- B .;j,.• Parcel Tat Added: Date B,
Receipt# Dare Method Amount$
i:\Building\Forms\RegPermirAction.doe Rev 05/25/2012
TIGARD
City of Tigard
June 3, 2016
ADT LLC
Attn: Lori McMurphy
7989 SW Cirrus Dr
Beaverton, OR 97008
Re: Permit No. ELR2015-00279
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9445 SW Locust St
Project Name: Tigard Orthopedic Fracture
Job No.: N/A
Refund Method: ® Check#221179 in the amount of$67.20.
❑ Credit card"return" receipt in the amount of$
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 customer cancelled job. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
<0A12141 ----
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
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: ADT TLC DATE: 5/26/2016
Attn: Lori McMurphy
7989 SW Cirrus Dr REQUESTED BY: Dianna Howse
Beaverton, OR 97008
TRANSACTION INFORMATION:
Receipt#: 400788 Case#: ELR2015-00279
Date: 11/25/2015 Address/Parcel: 9445 SW Locust St
Pay Method: CreditCard Project Name: Tigard Orthopedic Fracture
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees.
1. a !'' ^ 1111;4",';':14;F:..,:`:'
TWI, , pton Prom Rect�ipt.. ,—*:01 �A,eitll utast ' ' `�:t x ,�a6.1`'Pa, r
Exact.le..Buil.'{s::Permit Fee . ', i•1e ' :,3,0011004144Q ' .-$ ,:il
Restricted Energy Permit 220-0000-43103 $60.00
12%State Surcharge 100-0000-24001 7.20
TOTAL REFUND: $67.20
APPROVALS: SIGN TE:
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: 4/..7//6 By: 4SiTY
I:\Building\Refunds\RefundRequest.doc x 09/01/2010