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PFI2017-00095 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT = . Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • w����.tigard-car. c � TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Check(✓)one REFUND OR Name: Ciprian Vesa INVOICE TO: (Business or Individual) Mailing Address: 4616 SW 42nd Pl. City/State/Zip: Portland, Oregon 97221 Phone No.: 503-209-0544 PLEASE TAKE ACTION FOR THE ITEMS) 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 #: PFI2017-00095 Site Address or Parcel #: 14079 SW 119"Pl,Tigard, Oregon 97223 Project Name: Atrium Homes LLC. Partition Subdivision Name: Lot #: EXPLANATION: Refund 90% of the cash assurance, the remaining 10%is held for maintenance assurance for up to one year from 10/25/17 Signature: Date: .Y 7- Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. FOR OFFICE USE ONLY Route to Sys Admin: Date By_ Route to Records: Date B Refund Processed: Date Invoice Processed: Date B Permit Canceled: Date /V Parcel Tag Added: Date B i:\Bwlding\Forms\ReqPenTutAction-092314.doc W17 TIGARD City of Tigard November 20, 2017 Atrium Homes Attn: Ciprian Vesa 4616 SW 42nd Pl Portland, OR 97221 Re:Permit No. PFI2017-00095 Dear Applicant: The City of Tigard has processed a refund for the deposit of fees on the above referenced permit for the following: Site Address: 14079 SW 119`h Pl Project Name: Atrium Homes LLC Partition Job No.. N/A Refund: ® Check #226724 in the amount of$3,150.00. ❑ Credit card "return" receipt in the amount of$ ❑ Trust account"deposit" receipt in the amount of$ Notes: Refund 90% of customer deposit. Remaining 10% to be held for maintenance assurance for up to one year from 10/25/2017. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. 9 Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 0 www.tigard-or.gov City of 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: Ciprian Vesa DATE: 11/8/17 Atrium Homes LLC. 4616 SW 42nd Pl REQUESTED BY: Al Dickman Portland, Oregon 97221 Senior Engineering Technician 503-209-0544 TRANSACTION INFORMATION: Receipt#: 413131 Case#: PFI2017-00095 Date: 10/3/17 Address/Parcel: 14079 SW 119thPl Pay Method: -en ri'-C 0)(-Crie- Project Name: Atrium Homes LLC. Partition EXPLANATION: I'l - Vee.Dessrtptc O V dnz Receipt eventite Account No. Reid r Engineering cash assurance bond 100-0000-22000 $3,150.00 olf ST© fti Un- TOTAL REFUND: $33-150.00 APPROVALS: SIG ATURES D 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 FOR TIOU SVSTEIVI IN STRAT TI. Case Refund Processed: Date: 1 (o B I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Atrium Homes, LLC Site Address: 14059 SW 119TH PL Receipt Number: 416567 - 04/06/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00095 $-3,150.00 Total: $-3,150.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 226724 DROWSE 04/06/2018 $-3,150.00 Payor: Ciprian Vesa, Atrium Homes LLC Total Payments: $-3,150.00 Balance Due: $3,441.50 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: Atrium Homes, LLC Site Address: 14059 SW 119TH PL Receipt Number: 413131 - 10/03/2017 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00095 Customer Deposit 100-0000-22000 $3,500.00 Total: $3,500.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 32903492 SWAR R E N 10/03/2017 $3,500.00 Payor: Atrium Homes Total Payments: $3,500.00 Balance Due: $0.00 a Page 1 of 1