Permit Support Document (41) E F IVE
City of Tigard • COMMUNITY DEVELOPMENT DEPAR'1'MEN1'
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DEC 5 2017
. Request for Permit Action
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IT OF GA
T I CT' �+R p 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti ar -or. ov
TO: CITY OF TIGARDV 0 1 0
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 /Z/Tt"/7 4
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner feApplicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Centerline Solutions Inc.
Mailing Address: 6623 NE 78th Court,Suite B-1
City/State/Zip: Portland,OR 97218
Phone No.: 971-270-1930
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (i):
d 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 .rovide explanation below
p p )
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: BUP2016-00317
Site Address or Parcel#: 17026 SW Friendly Lane Beaverton,OR 97007
Project Name: POR Barrows-Generator replacement
Subdivision Name: Lot#:
EXPLANATION: Please cancel permit.No refund will be requested.
Signature: 67.1,142-- / 1, ` - Date: 12/05/2017
Print Name: Alice Butler
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date J 6 /::r ,7*'--Ir.
Refund Processed: Date /2712-,//; By ...4:2704 Invoice Processed: Date By
Permit Canceled: Date/2/2,f-//7 By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_02314.doc
11111 .
a
TIGARD
City of Tigard
January 18,2018
Centerline Solutions Inc.
Attn: Alice Butler
6623 NE 78th Court, Suite B-1
Portland, OR 97218
Re: Permit No. BUP2016-00317
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 17026 SW Friendly Ln
Project Name: POR Barrows - Generator Replacement
Job No.: N/A
Refund Method: ® Check#227172 in the amount of$338.60.
❑ Credit card "return"receipt in the amount of$
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 job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,,
tit
91
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
illA
m City of Tigard
T i GA R D Accela Refund Request
This form is used for refund requests of land use,development engineering and building permit
application fees. Receipts,documentation and the RequestforPermitAction 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: Centerline Solutions Inc. DATE:
6623 NE 78th Ct, Ste B-1 12/28/2017
Portland, OR 97218 REQUESTED BY:
Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 407239
Date: 11/3/2016 Case#: BUP2016-00317
Pay Method: Check Address/Parcel: 17026 SW Friendly Ln
Project Name: POR Barrows -Generator Repl
EXPLANATION: Per applicant's request. Refund 80%of permit fees.
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, 74.,¢ s m .4a: E., ;' v ' P `4 s2sfx ''`j 'x," d e $302.32'da ''arrwai*�i §Ea' �%� 230-0000-43104Building Permit
12%State Surcharge
100-0000-24001 36.28
TOTAL REFUND: $338.60
APPROVALS: SIG ATUR 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
Case Refund Processed: DateSI r°' �
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
111‘11
CITY OF TIGARD RECEIPT
■ . 13125 SW Hall Blvd.,Tigard OR 97223
- 503.639.4171
TIGARD
Project Name: Verizon
Site Address: 17026 SW FRIENDLY LN AiL.
I Receipt Number: 416601 - 04/06/2018
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
BUP2016-00317
$-338.60
Total: $-338.60
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 227172 DHOWSE
Payor: Centerline Solutions Inc. 04/06/2018 $-338.60
Total Payments: $-338.60
Balance Due: $338.60
Page 1 of 1
I
CITY OF TIGARD RECEIPT
III .4
1 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Verizon
Site Address: 17026 SW FRIENDLY LN
I Receipt Number: 407239 - 11/03/2016
I
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER
PAID
BUP2016-00317 Permit Fee-Additions,Alterations, 230-0000-43104
Demolition $377.90
BUP2016-00317 12%State Surcharge-Building 100-0000-24001
BUP2016-00317 Plan Review $45. �--
230-0000-43106 $245.6464
Total: $668.89
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 16079 DADAMSKI 11/03/2016
Payor: Centerline Solutions LLC $668.89
Total Payments: $668.89
Balance Due: $105.00
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