Permit Support Document (128) City of Tigard • co r it yI I 1)1��V .':1.<] ,1.1'.> 1` DF1 Rl51lt y°)
Request fc;t Permit Action 0 1
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T1GARD 13125 S\\ 1 lall Blvd. • Tigard, ()rcgol 9"-223 • 503-718-243') • ,,,,,a-,6,.A a.rard (ir ,,,, 9k`I
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TO: CITE OF TIGARD . . , '
Budding Division
1325 SW 1 jail Blvd., 1'i9.ard, ()R 9722 AUG 1 8 2016
Pli,me: 503-718-2-139 l•ax: 5O. ,598-1961) "l ig.ir•.<lBialcling1'c 4 alit t it��110 ,r u,A
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REFUND OR Nam.:
INVOICE
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TIGARD
City of Tigard
September 23, 2016
Environmental Works
Attn: Ryan Meyer
2634 SE Steele St.
Portland, OR 97202
Re: Permit No. PLM2016-00416
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14160 SW Hall Blvd
Project Name: Finley Sewer Install
Job No.: N/A
Refund Method: ® Check#222411 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 customer could not hook up to city sewer main
and easement was not granted. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
40d5420}1-.C.___
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
1111
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: Environmental Works DATE: 9/16/2016
Attn: Ryan Meyer
2634 SE Steele St REQUESTED BY: Dianna Howse
Portland, OR 97202
TRANSACTION INFORMATION:
Receipt#: 405489 Case#: PLM2016-00416
Date: 8/9/2016 Address/Parcel: 14160 SW Hall Blvd
Pay Method: CreditCard Project Name: Finley Sewer Install
EXPLANATION: Could not hookup to city sewer main and easements were not granted;refund 80%of
3, 7 permit fees.
REF N1I F S ATIO 4 s aiv"{c a n µ r 2 ey .a Laa r r"r {°k a ' �' `
r p t o- e �� tw -
Exa l eu4g Permit ' s .:, 11rt.:Y K. ,= 7d .. . : le !�,. �6!- 4310; �i iI AV ,f
Plumbing permit 230-0000-43101 $58.00
12%State Surcharge 100-0000-24001 6.96
TOTAL REFUND: $64.96
APPROVALS: SIGN. URES DATE:
If under$5,000 Professional Staff ir � 1-C.—
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
.i .: hF(.R' DEIVIARK SSSS` EM„APM IST:laT. f;I NV$E Y, '1
Cas:L.'''-':' ,'4i.:4%;::''
Refund Processed: I Date: /Op//fes By
I:\Building\Refunds\RefundRequest.doc x 09/01/2010