PFI2016-00089 A
City of Tigard
November 20, 2017
Polygon WLH,LLC
703 Broadway St., Suite 510
Vancouver,WA 98660
Re: Permit No. PFI2016-00089
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: 16808 SW Friendly Ln
Project Name: River Terrace East
Job No.: N/A
Refund: ® Check#226777 in the amount of$468,607.00.
❑ Credit card"return"receipt in the amount of$
❑ Trust account "deposit" receipt in the amount of$
Notes: Refund 100% of customer deposits for grading and erosion control. Permit has
been issued and work fully assured.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
NJ
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 PerrrmitAction 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: Polygon WLH, LLC DATE: 11/6/2017
703 Broadway St., Suite 510
Vancouver, WA 98660 REQUESTED BY: Dianna Howse
MW
TRANSACTION INFORMATION:
Receipt#: 405310 Case#: PFI2016-00089
Date: 8/2/2016 Address/Parcel: 16808 SW Friendly Ln
Pay Method: Check Project Name: River Terrace East
EXPLANATION: Refund customer deposits for grading and erosion control. Permit has been issued and
all work fully assured. Refund 100%of deposits
REFUND INFORMATION: .
Fee Description'From Receipt Revenue Account No. Refund
Example: Building Pel L Fee Example: 2300000-43104 $"Axriottnt
Customer Deposit 100-0000-22000 $400,000.00
Customer Deposit 100-0000-22000 68,607.00
TOTAL REFUND: $468,607.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager on
If under$50,000 City Manager
If over$50,000 Local Contract Review Board /V e
f'"4
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY 4- ,
Case Refund Processed: Date: B : ,
I:\Building\Refunds\Refund Req uest.doc x 09/01/2010
City of Tigard * COMMUNITY DEVELOPMENT DEPARTMENT
=
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 - «nvw.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor t4 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or IndWidual) ��L`�6, L4-yL 1-( L L.C
Mailing Address: 7 D 3 f gtS4,.," �j T 5 c9 14r-JE.
City/State/Zip: Aiu Lav V F,(L- [,--�k , L6 0
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ?f 1 2-,0 1(0 -00061
Site Address or Parcel#: 116$ O $ fpi E-P-31 L T LN
Subdivision Name: 110ta, "T CAC#tC.L M51 Lot#:
EXPLANATION: f-94-u PD C,*xlj Leri i T"S ee 1A;b0-J6-j 6m/,r
Signature: Date: A0 )16Z17
Print Name: I oa,. tv,w/rf�
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 B Invoice Processed: Date B
Permit Canceled: Date Parcel Tag Added: Date B
I:\Building\Forms\RegPemutAction_09_314.doc
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: River Terrace East
Site Address: 16808 SW FRIENDLY LN
��u UVJ
Receipt Number: 416584 - 04/06/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12016-00089 $468,607.00
Total: $-468,607.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226777 DHOWSE 04/06/2018 $468,607.00
Payor: Polygon WLH, LLC
Total Payments: $-468,607.00
Balance Due: $468,607.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: River Terrace East
Site Address: 16808 SW FRIENDLY LN &J//67
Receipt Number: 405310 - 08/02/2016
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12016-00089 PFI Permit Fee 100-0000-43114 $83,693.32
PF12016-00089 Eng/Maintenance 200-0000-43119 $61,854.96
PF12016-00089 Customer Deposit 100-0000-22000 $400,000.00,—
PF12016-00089 Erosion Control Fee 100-0000-43134 $6,461.40
PF12016-00089 Customer Deposit 100-0000-22000 $68,607.00, y-
Total: $620,616.68
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 071087 BRUEF 08/02/2016 $620,616.68
Payor: Polygon WLH, LLC Oreong Permit Account
Total Payments: $620,616.68
Balance Due: $0.00
Page 1 of 1