Permit Support Document (52) . ,
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City of Tigard , COMMUNITY DEVELOPMENT DEPARTMEN F(1F1 VED
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: c Request for Permit Action
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T IG A RD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439•www.tipard . 4 2 2017
C11 Y tn4 I/GARD
TO: CITY OF TIGARD
Building Division BUILDING DIVISION
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: 0 Owner Eio Applicant jj Contractor 0 City Staff
Check(,)one
REFUND OR Name:
INVOICE TO: (Business or Individual) L ft) 1:? Ra3cirs Etec.frycil t C-eitiv'acfors inc
Mailing Address: 2656 Mdlrasyl i pr. „sm. Jab
City/State/Zip: Mfinarehitt 1 &04 34006
Phone No.: 770 - 77Z -11142-
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1):
Giji CANCEL/VOID PERMIT APPLICATION.
irsA REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: 1 C. 2b14-665g 7
Site Address or Parcel#: 1402 5W wash s Tion SUave Rd i-7.-rscoidt,e
Project Name: 0$61 i il:
Subdivision Name: Lot#:
EXPLANATION: - :t, e ,k ce _ ,c4 ,,,,a, .. - ..
Signature: 1 k _
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- ..,.._ ......›. Date: ?/7.-2....I
Print Name: ?ALAI moliseif
Refund Policx
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• Not morc than 80%of the application or plan review fec when an application is withdrawn or canceled before review effort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. —/ - /7, ,Py
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FOR OFFICE USE ONLY
Route to Svs Admits: Date 'IAA 0 Blift 17 Route to Records: Date 3 c.,23 4 By .17,
Refund Processed: Date 7, //7 :y . Invoice Processed: Date By
Permit Canceled: Date p- /y//7 By --. Parcel Tag Added: Date By
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TIGARD
September 21,2017 City of Tigard
Lin R Rogers Electrical Contractors
Attn: Paul Howell
2050 Marconi Dr., Ste. 100
Alpharetta, GA 30005
Re: Permit No. ELC2017-00587
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9402 SW Washington Square Rd
Project Name: Dick's Sporting Goods
Job No.: N/A
Refund Method: ® Check#226163 in the amount of$50.33.
0 Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
0 Trust account"deposit"receipt in the amount of$ .
Comment(s): Per applicant's request as job was cancelled. Refund 80%of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4d2l .f;37117-P -7—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
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_ 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: Lin R Rogers Electrical Contractors DATE:
9/14/2017
Attn: Paul Howell
2050 Marconi Dr., Ste. 100 REQUESTED BY: Dianna Howse
Alpharetta, GA 30005
TRANSACTION INFORMATION:
Receipt#: 412203 Case#: ELC2017-00587
Date: 8/7/2017 Address/Parcel: 9402 SW Washington Square
Pay Method: CreditCard Project Name: Dick's Sporting Goods
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80%of permit fees.
a
f�
i { $44
944&+ 220-0000-43103
12%State Surchar.a 100-0000-24001
5.39
TOTAL REFUND: $50.33
APPROVALS: SIG T 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
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Case Refund Processed: Date: � ..3 c 3 /d B
L•\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
; it 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Dick's Sporting Goods Miscellaneous Projects
Site Address: 9402 SW WASHINGTON SQUARE RD P01 A/.
Receipt Number: 416297 - 03/23/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELC2017-00587
$-50.33
Total: $-50.33
•
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226163 DHOWSE 03/23/2018 $-50.33
Payor: Lin R Rogers Electrical Contractors
Total Payments: $-50.33
Balance Due: $50.33
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CITY OF TIGARD RECEIPT
i . 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
TfC;ARD
Project Name: 2017 Dick's Sporting Goods Miscellaneous Projects
Site Address: 9402 SW WASHINGTON SQUARE RD P01
®2f6"/i✓R—e---
I Receipt Number: 412203 - 08/07/2017 I
CASE NO. FEE DESCRIPTION
REVENUE ACCOUNT NUMBER PAID
ELC2017-00587 Branch Circuits wo/Purchase Service or
Feeder 220-0000-43103 $56.18
ELC2017-00587 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 007814
Payor: Erika Brown PUBLICUSER108 08/07/2017 $62.92
Total Payments: $62.92
Balance Due: $0.00
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