Permit Support Document (100) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ki-1
711Request for Permit 4i4 �
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TIGARD 13125 SW Hail Blvd. •Tigard,Oregon 97223 . 503-718-2439 • ..... •...r „_ ...0 cc//G'
TO: CITY OF TIGARD c ):,,,,l/r1;97 ,
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Building Division V II I ,
13125 SW Hall Blvd.,Tigard,O. 97223
Phone: 503-718-2439 Fax: 503-598-1960 .:. .BuildingPenxits@tigard-or_gov7 //
FROM: gi Owner ❑ Applicant Contractor ' d City Staff
Check(✓)one
REFUND OR Name: ��
INVOICE TO: (Busing**or Individual) 4 n G 04 i>r r7
Mailing Address: /C? 8,5x. /7�2J 0 7
City/State/Zip: /p r--&-f A(lc/ C 9 7 2 Co
Phone No.: 3O 3 .. 6 3 6 S„ &7(
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of of gi:nal receipt and provide explanation below)_
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
E REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
?O_/. ,C %3.7_ _ ,
Permit#: �C
Site Address or Parcel..#: 9 765` 5r) ()-e-r7&Urd r �"
Project Name: .er y// Liiarii.J j/
Subdivision Name: 0U46-4e 8 .. S&4 Lot#: 57g
EXPLANATION: £up/cAa be parr?i t, Se.e / 2 020/6-- 00 L,
Signature: ]nate: 6,/zQ/-
Print Name: -.7—eiL - Lnt,2
Rrfirnd Policy c�//
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid ox 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 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 payer in the form of a check via US postal service,
3. Please allow 3-4 weeks for processing refund requests. �� — t
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FOR OFFICE USE ONLY
Route to S=s Admin: Date 4017//(p , 5'j Route to Records: Date 7 , + „ B ((2
Refund Processed: Date '/' rC By Invoice Processed: Date By
Permit Caasceled: Date 7 .2, / B ' Parcel Tag Added: Date B
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TIGARD-
City of Tigard
July 29, 2016
Rose City Refrigeration Heating&Air LLC
Attn: Jeff Pangborn
PO Box 19207
Portland, OR 97280
Re: Permit No. MEC2016-00437
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9765 SW Ventura Ct
Project Name: Merkyl/Vandegrift
Job No.: N/A
Refund Method: ® Check#221884 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 this was a duplicate permit and work was
completed under MEC2016-00452. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
r
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
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City of Tigard
TIGARD Accela Refund Request
Ci
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: Rose City Refrigeration Heating& DATE: 7/21/2016
Air LLC
Attn: Jeff Pangborn
PO Box 19207 REQUESTED BY: Dianna Howse
Portland, OR 97280
TRANSACTION INFORMATION:
Receipt#: 404562 Case#: MEC2016-00437
Date: 6/20/2016 Address/Parcel: 9765 SW Ventura Ct.
Pay Method: CreditCard Project Name: Merkyl/Vandegrift
EXPLANATION: Per applicant's request as this was a duplicate permit, see MEC2016-00452. Refund
80% of permit fees.
R8FUND INFORMATION:.
Pee Description From Receipt Revenue Account Nu. Rind,',
Example: Building Permit Fee' Example: 2300000-43104 $ oit.-`
Mechanical Permit Fee 230-0000-43102 $72.00
12%State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGN TU S/ ATE:
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: 2/2- /p, By: `
I:\Building\Refunds\RefundRequest.doc x 09/01/2010