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Permit Support Document (20) JAN/09/2017/MON 15:00 Northside Electric FAX No. 5033640248 F. 001/001 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT'' t '.1 3 Request for Permit Action }AN :?017 'FIG<i A Fc F Ji 13125 SW Hail Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www ti c4A ' g; p TO: B1JILI)L' CITY OF TIGARD �t Building Division / k 13125 SW Hall Blvd.,Tigard,OR 97223 7 t' '" Phone: 503-718-2439 Pax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner v�Applicant Contractor ❑ City Staff Check(1 one REFUND OR Name: ( r INVOICE TO: (8usines3 or Individual) .3 ,^C �/�c, Mailing Address: 2.3 2 3 City/State/Zip: l Q Fr Cp�, '1 30 9 Phone No.: C503) 5 3 —4[1 7 q PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL/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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). Permit#: ELC 20i 1 ©001 n1 Site Address or Parcel#: j `O • �i • Cd Project Name: c`';`V\\eka_ Subdivision Name: Lot#: EXPLANATION: ")c_x_rdeAcks tc), wry LA.,rnbzr r 0 'a1P,it1 loot 6.44, Le. 90/7—000 gr)Signature: C/ Date: I —CI _-17 Print Name: „�r L,,,r e_ Refund Poi.t1 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 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. •Z — 3 7 2 r1 C 2 /9. 74' //. 1/ _ /3 7a7 2 a ,2 7,5 FOR OFFICE USE ONLY Route to Sys Admin: Date / 9 /7 & t Route to Records: Date /7 By ..j' 7 Refund Processed: Date •,2 ,24//7 By• •! Invoice Processed: Date By Permit Canceled: Date .z / By t fes. "Parcel Ta_Added: Date By l:\BuilSling\Powns\RcgPemitActioe_0923 440. III V TIGARD City of Tigard February 9,2017 Northside Electric Attn: Ginny Kline PO Box 12323 Salem, OR 97309 Re: Permit No. ELC2017-00017 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 9530 SW Washington Square Rd Project Name: Athleta Job No.: N/A Refund Method: ® Check#223755 in the amount of$110.18. ❑ Credit card"return"receipt in the amount of$ 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 they purchased the wrong number of branch circuits and pulled another permit ELC2017-00018 for the correct amount. Refund 80% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Ad;29/0707e_ 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 TIGAKD 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: Northside Electric DATE: 2/2/2017 Attn: Ginny Kline PO Box 12323 REQUESTED BY: Dianna Howse Salem, OR 97309 TRANSACTION INFORMATION: Receipt#: 408255 Case#: ELC2017-00017 Date: 1/6/2017 Address/Parcel: 9530 SW Wash Square Rd Pay Method: CreditCard Project Name: Athleta EXPLANATION: Per applicant's request as they purchased the wrong number of branch circuits. Pulled another permit ELC2017-00018 for the correct number. Refund 80%of permit fees. fiTARVIV t'�yF4� ,�a.44.m Rxr - " �s" k' r *n' ai Fee1):4cee roRd e +S • 3 ¢E r ""',r `"yr--�s;:''+',c-y+. &" ,z." y, yv.. � :,a , ;gstl :ti:it" s -. a t � . ,.Pttt, Electrical permit 220-0000-43103 $98.37 12% state surcharge 100-0000-24001 11.81 TOTAL REFUND: $110.18 APPROVALS: SIG► U' S/DATE: 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 r 4 zwr Case Refund Processed: Date: ,1607 By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010