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Permit Support Document (62) VOID q 7-1 F8202019 City ©f Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action on l c,. Et l l 13125 SW Hall Blvd. •Tigard,Oregon 97223.503-718-2439•www,tig rd-ox,gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax 503-598-1960 TsgardBualdingPesmits®agard-or gov FROM: ❑ Owner N1/4Applicant IiContractor ❑ City Staff Check M one REFUND OR Name: �//�/y INVOICE TO: nr individual) . LC `_ _ .KCCI.Vat a MailingAddress: 105/.1-4 St rtt 521, City/State/Zip: MI ho OR ctl 2J 2 Phone No.: 503. (41.5L0- (o(OI PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED(1): ___y, CANCEL/VOID PERMIT APPLICATION. [rJ 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). Permit#: t'Lm 2.0 1,9 - COO 40 Site Address or Parcel#: 10-70 Zak) eCi-inn LL 0d Lance Project Name: 1 ( Subdivision Name: P ,� ted I V o 5 Lot#: EXPLANATION: ThA9 orl,War2,1- too*, \rv2k.„) 10tertetithetited Signature: gelnkeyvbAn Date: 24)-t Print Name: �e�ea. &haenb09,n Refund Policy 1. The city's Community Development Director,Snarling Official or City Engineer may authorize the refund of • Any fee which was erroneously paid or collected. a Not more than 80%of the application or plan review fee when an application a withdrawn or canceled before review effort has been expended.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. AU 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. ,f', 70 4 P/• .-c) " l - , 02- Mit C)t=t"t(:l. I SI: 11N1 Route to Sys Admin: _ Date By Route to Records: Date $ /t. By r Refund Processed: Date 3/2 5/, By Invoice Processed: Date By Permit Canceled: Date V:2-9-/( By By ,/ Parcel Tqg Added: Date By TABuclding\Forms\ReqPermitA1285i&dor . TIGARD City of Tigard April 4, 2019 Root Excavation 10824 SE Oak St, #322 Milwaukie, OR 97222 Re: Permit No. PLM2019-00040 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 11070 SW Cottonwood Ln Project Name: Halstead Job No.: N/A Refund Method: ® Check#231721 in the amount of$64.96. 0 Credit card"return"receipt in the amount of$ . 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, <0;7707,e)-Je-- 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 City of Tigard TI c A u 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 Request forPermit 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: Root Excavation DATE: 3/29/2019 10824 SE Oak St, #322 Milwaukie, OR 97222 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 421306 Case#: PLM2019-00040 Date: 1/30/2019 Address/Parcel: 11070 SW Cottonwood Ln Pay Method: CreditCard Project Name: Halstead EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees. � � �. m ,. �_ , w fx a Lt. a as as§�f2 Plumbin. Permit 230-0000-43101 $58.00 12%State Surchar.e 100-0000-24001 6.96 TOTAL REFUND: $64.96 APPROVALS: SIGNAT E D TE: If under$5,000 Professional Staff ,C.il' If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board Case Refund Processed: Date: #"....r /y By: i ' I:\Building\Refunds\RefundRequest.doc x 09/01/2010