PFI2016-00266 City of Tigard 0 Co),'\INIL'NITS' DEX'ELOP,%IENT DEP.NR'I',N1EN"1'
Request for Permit Action
13125 S\V Hall Blvd. • "Tigard, Oregon 97223 • 503-718-2439 • wwn".tigar -ongov
TO: CITY OF TIGARD
Building Division
13125 SAX'Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Cite Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business r,r Individual) or ko vc,% It V
Nlailing Address: q/// S w SaZ'%-'o A..�e,
Cite/State/Zip: Pe t�`aMdt� b 9172 21
Phone No.: so3-3►3- ga57
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
❑ C NGF—J 'OID PERMIT APPLICATION.
REFUND P RN1IT FEES (attach cop);of original receipt and provide explanation below).
RE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REN10VE/REP1,ACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: FP/01 016- Do li(i
Site Address or Parcel #: &6;0 So L9aj v%w4 -t-e,
Subdivision Name: K.-m, S V+ Lot #:
EXPLANATION: Ple*3t V'C L 6k CuJA•w.,e
A%k +- S ,,.irk 1►��.,5 �t'rr� Co,r+�p It
Signature: Date: S1.12`4�17
Print Name: J•�•►.,� (,:g tti
Refund Policy
1. The cit�"S(:ommunitV Development Director,Building Official or Cit} Fnlrineer may authorize the refund of:
• Any fee which was erroneously Paid or collected.
• Not more than 80°0 of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80°%i;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 I IS postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Svs admin: Date Bt- Route to Records: Date-- /
Refund Processed: Date--s L /7 By -Invoice Processed: Date By
Permit Canceled: Date n/ By Parcel Tag Added: Date By
1:\Huildin \I��rms\RryPcrmit NoMn_092314.doc
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City of Tigard
June 1, 2017
Mark Kovalev
4111 SW 52nd Ave.
Portland, OR 97221
Re:Permit No. PFI2016-00266
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: 6620 SW Walnut St.
Project Name: Kovalev
Job No.. N/A
Refund: ® Check#224862 in the amount of$1,990.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account"deposit" receipt in the amount of$
Notes: Refund 100% of customer deposit for work completed.
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
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: Mark Kovalev DATE: 5/26/2017
4111 SW 52nd Ave.
Portland, OR 97221 REQUESTED BY: Dianna Howse
Jonny Gish
TRANSACTION INFORMATION:
Receipt#: 408011 Case#: PFI2016-00266
Date: 12/21/2016 Address/Parcel: 6620 SW Walnut St
Pay Method: CreditCard Project Name: Kovalev
EXPLANATION: Refund 100% of customer deposit for work completed.
REFUND INFORMATION:
Fee"Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 234000-43104 ' $Amount
Customer Deposit 100-0000-22000 $1,990.00
TOTAL REFUND: $1,990.00
APPROVALS: SIGNATURES 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
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date:
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: Kovalev
Site Address: 6620 SW WALNUT TER
Receipt Number: 415893 - 03/02/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12016-00266 $-1,990.00
Total: $-1,990.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 224862 DHOWSE 03/02/2018 $-1,990.00
Payor: Mark Kovalev
Total Payments: $-1,990.00
Balance Due: $1,990.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 408011 - 12/21/2016
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12016-00266 Customer Deposit 100-0000-22000 $1,990.00
Total: $1,990.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 03067J LSMITH 12/21/2016 $1,990.00
Payor: Mark Kovalev
Total Payments: $1,990.00
Balance Due: $0.00
Page 1 of 1