Permit Support Document (34) City of Tigard • COMMUNITY DEVELOPMENT DEI'ARTMB\T��7
IN
Request for Permit Action
IN
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.ti,�. I E
TO: CITY OF TIGARD JUN 1 2017
Building Division CITY OF TIGARD
13125 SW Hall Blvd.,Tigard,OR 97223 BUILDING DIVISION
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ( Applicant E Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) �'"",( C
/
Mailing Address: Lit
City/State/Zip: Dti f 1, I,r
Phone No.: - j, ') i
PT.FASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICATION.
M 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
g (do not cancel permit).
Permit#: ‘1...-C,
Lt 1—"` D D42
Site Address or Parcel#: V IV I '-1-1 1124
Project Name:
Subdivision Name: Lot#:
EXPLANATION: . 4' r� !t ' i _ �- ( 1
ilk i ° ► A1 1 Ad .1 ,Meirrinallialff=ini
Signature: ;' ' 1r ' Date: ,i ID t
Print Name: ltzl If' _
Refund 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 or plan review fee when an application is witi drawn 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. /� u //, Y Y.
C . 7` — _ ,c, 3 9 - 1.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date kg !7 By '. Route to Records: Date 3 2.-/�' B ��•
r=
Refund Processed: Date / /? By 4'.'AL Dice Processed: Date By
Permit Canceled: Date J/ By <_ %" arcel Tag Added: Date By
I:\Building\Norms\RegpermitAcrion_0 2314.c oc
TIGARD
City of Tigard
July 26,2017
Bear Electric
Attn: Sarah Osterhoudt
PO Box 389
Donald, OR 97020
Re: Permit No. ELC2017-00423
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 12898 SW Takena Ct
Project Name: Robertson
Job No.: N/A
Refund Method: ® Check#225369 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 the job was cancelled. Refund 80% of permit
fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/444" 42---"
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
cF,
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: Bear Electric DATE: 7/6/2017
Attn: Sarah Osterhoudt
PO Box 389 REQUESTED BY: Dianna Howse
Donald, OR 97020
TRANSACTION INFORMATION:
Receipt#: 411108 Case#: ELC2017-00423
Date: 6/8/2017 Address/Parcel: 12898 SW Takena Ct
Pay Method: CreditCard Project Name: Robertson
EXPLANATION: Per applicant's request as job was cancelled;refund 80%of permit fees.
Y ®Etat
.t` 3
Electrical Permit 220-0000-43103 $44.94
12%State Surchar•a 100-0000-24001 5.39
TOTAL REFUND: $50.33
APPROVALS: SIGN 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
",-7'14:'“IPOIEUMOA4UCSN7ON04)0040411WW4A#014tWOr
Case Refund Processed: Date: 072.- f-' By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
111114
CITY OF TIGARD RECEIPT
it 13125 SW HaII Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Robertson
Site Address: 12898 SW TAKENA CT
Receipt Number: 415911 - 03/02/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00423 $-50.33
Total: $-50.33
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 225369 DROWSE 03/02/2018 $-50.33
Payor: Bear Electric
Total Payments: $-50.33
Balance Due: $50.33
Page 1 of 1
II
CITY OF TIGARD RECEIPT
g 1 ' 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Robertson
Site Address: 12898 SW TAKENA CT
IReceipt Number: 411108 - 06/08/2017 I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
ELC2017-00423 Branch Circuits wo/Purchase Service or 220-0000-43103
Feeder
$56.18
ELC2017-00423 12%State Surcharge-Electrical
100-0000-24001 $6.74
Total: 662.92
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 818090 PUBLICUSER108 06/08/2017
Payor: Sarah Osterhoudt $62.92
Total Payments: $62.92
Balance Due: $0.00
Page 1 of 1