Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT EIV
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Request for Permit Action
T r c,A R o 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •w ...ti ar A 101'
TO: CITY OF TIGARIJ r
Building Division
13125 SWHall Bv
Blvd.,Tigard,OR 97223 V Li
Phone: 503-718-2439 Pax: 503-598-1.960 TigardBuildingPermits@tigard-or.gov���" �f 7
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
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REFUND OR Name:
INVOICE TO: (Business or Individual) Garner Electric WA LLC
Mailing Address: 402 Valley Ave NW Suite 106
City/State/Zip: Puyallup, WA 98371
Phone No.: _ 253-872-6051
PLEASE TAKE ACTION P'OR THE ITEM(S) CHECKED (✓):
❑ CANCEL/STOI:D PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
Li INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
E REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ELC2017-00381
Site Address or Parcel#: 15270 SW Thames Lane
Project Name:
Subdivision Name: River Terrace Lot#: 70
EXPLANATION: Permit was pulled by mistake, We will be using minor labels for this 'ob.
Signature:
]late: 5/2 7
Print Name: Alicia Gentefe
Refun<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• Not more than 80%of the application ox plan review fee when an application is withdrawn or canceled before review effort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. r
./ . f
FOR OFFICE USE ONLY
Route to S s Adrnin: Date B Route to Records: Date 34r/ j
Refund Processed: Date ., jar/ B g' Invoice Processed: Date By
Permit Canceled: Date � ► T—Parcel Tag Added: Date By
I:\Building\Forms\1tegpcmnitAction_s.2314,.oc
114 le
TIGARD
City of Tigard
June 1,2017
Gamer Electric Washington LLC
Attn: Alicia Gentele
402 Valley Ave NW,Suite 106
Puyallup,WA 98371
Re: Permit No. ELC2017-00381
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15270 SW Thames Ln
Project Name: River Terrace Northwest,Lot 70
Job No.: N/A
Refund Method: ® Check#224850 in the amount of$50.33.
❑ Credit card"return"receipt in the amount of$ .
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 a minor lable was used. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
1"' 14.47-4Y1 ---
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 PermitAction 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 forprocessing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Gamer Electric Washington LLC DATE: 5/26/2017
Attn: Alicia Gentele
402 Valley Ave NW, Suite 106 REQUESTED BY: Dianna Howse
Puyallup,WA 98371
TRANSACTION INFORMATION:
Receipt#: 410834 Case#: ELC2017-00381
Date: 5/25/2017 Address/Parcel: 15270 SW Thames Ln
Pay Method: CreditCard Project Name: River Terrace Northwest,Lot
70
EXPLANATION: Per applicant's request as they will use a minor label. Refund 80%of permit fees.
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l�iw._ _ _ s....'�,u�.'>:.,_...._3;:.,�.,.,.hm�r. _..��.s.a_.. s .va�..��� �* ' ' ��,..... ,..'`1,>,} a �.. '`i �
Electrical Permit 220-0000-43103 $44.94
12%State Surchar•a 100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SIG URES/DATE:
If under$5,000 Professional Staff 4F-'41612-4v;
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
SYS° 50. 'ORA TiOX4-VSB-4:41-417'kilel"41'
Case Refund Processed: Date: 1 g /a By: j /
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
Ai
it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
-FIG AR.D
Project Name: River Terrace 77
Site Address: 15150 SW MISSOURI PL �� �,\
Receipt Number: 415895 - 03/02/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00380 $-50.33
Total: $-50.33
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 224850 DHOWSE 03/02/2018 $-50.33
Payor: Garner Electric Washington LLC
Total Payments: $-50.33
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
1 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
I Receipt Number: 410834 - 05/25/2017
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00381 Branch Circuits wo/Purchase Service or 220-0000-43103 $56.18
Feeder
ELC2017-00381 12%State Surcharge-Electrical 100-0000-24001 $6.74
Total: $62.92
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 00636G PUBLICUSER134 05/25/2017 $62.92
Payor: Felicia Horan
Total Payments: $62.92
Balance Due: $0.00
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