Permit Support Document (55) City of Tigard • COMMUNITY DEVELOPMENT DEPARI6E
1 p ,
"II " Request for Permit Actionmy--
RECEIVE')
I i k;A R n 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.govJ U L 26 2018
TO: CITY OF TIGARD
CITY OF TIGARD
Building Division BUILDING DIVISION
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPcrrnits@tigard-or.gov
FROM: ❑ Ovner. ❑ Applicant E Contractor ❑ City Staff
("heck(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 1 n R bcp S I e c+r l c a i C a n firer r fico v s INC,
Mailing Address: 2050 YY10,YCOYl1 Zr. Ste 100
City/State/Zip:. AA?NA yeitQ, ( -1i 3000 6-
Phone
Phone No.: 1-1 p - 11 2.- 314 00
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 CANCEL/VOID PERMIT APPLICATION.
NREFUND 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 CONTRACTORCOON PERMIT(do not cancel permit).
r
Permit#: 201S- OO,1 y$
Site Address or Parcel#: ( 11%00 SV' SegUo1Q -PKwy II C,QYCli 'c 9122Lt
e
Project Name: Home 17epOff- 4602
Subdivision Name: Lot#:
EXPLANATION: 110 WQrIC WaS Clone ; in lias been •
cctx c e l LecC,
gn �... Date: 1 J 25 its
Signature:
Print Name: c u. ft 11
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. ,7 C, ® _ 5c .1"'i'' / - 7"----
2. 6,
z...2.. 6, 3 - 6 L /o / S'.
7" 3 ..54, 9F 7,4 , ,„2j
FOR OFFICE USE ONLY __
Route to S s Admin: Date B Route to Records: Date fQ/ " B '1%
Refund Processed: Date S; r B, Invoice Processed: Date By
`(
Permit Canceled: Date ''/ /fr.-- By Parcel Tag Added: Date BY
I:\Building\Forms\RegPermitAction_09231 .doc
IIIIII
- q
TIGARD
City of Tigard
August 9,2018
Lin R Rogers Electrical Contractors
Attn: Paul Howell
2050 Marconi Dr., Suite 100
Alpharetta, GA 30005
Re: Permit No. ELC2018-00448
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 14800 SW Sequoia Pkwy
Project Name: Home Depot 4002
Job No.: N/A
Refund Method: ® Check#229398 in the amount of$56.98.
❑ Credit card"return" receipt in the amount of$
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,
if
`r ' '
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
.71 "
City of Tigard
TI G A K 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 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: Lin R Rogers Electrical Contractors DATE: 8/3/2018
2050 Marconi Dr, Suite 100
Alpharetta, GA 30005 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 418207 Case#: ELC2018-00448
Date: 7/5/2018 Address/Parcel: 14800 SW Sequoia Pkwy
Pay Method: CreditCard Project Name: Home Depot 4002
EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees.
��c74 ® ami* r® m ac i i �e4�
Electrical Permit 220-0000-43103 $50.88
12% state surcha.•e 100-0000-24001 6.10
TOTAL REFUND: $56.98
APPROVALS: SIGN4`4J DATE:
If under$5,000 Professional Staff �l�fj�/
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 BoardWI .
Case Refund Processed: Date: �'S/)J By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010