Permit Support Document (65) VOID
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City of Tigard • COMMUNITY DEVELOP EN DEPARTMENT
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Request for Permit Action i`'\' 2 2018
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7 i C;ARD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.g�y;)$i, r 3
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:
INVOICE TO: (Business or individual) /"OGU` QJel�..cg.Un /�° i v' �7 ; :e.
Mailing Address: /00e t,g/17y 1 /r`�',,,o(ri A '
City/State/Zip: /tl,P 2rt Oat' P 7/0.2
Phone No.: ,5 —(550 ^ 40.2,7
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#: )(tee o20!g- 190(0.- -)
Site Address or Parcel#: 11(p 20 5(A, "Bait, imxt -r1u 11 ia.. t `ck
Project Name: taxr1�2-� d
Subdivision Name: Lot#:
EXPLANATION: Alp k co /t � .?LIZ
CiSignature: Date: �'1
Print Name: */^f:5/5,tot' Q ( 18
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 9' 0 .-
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date if, i9' By 4, T
Refund Processed: Date , By I ygice Processed: Date By
Permit Canceled: Date 9 By -.;i Parcel Tag Added: Date By
I:\Building\Porms\RegPermitAction_692 doc
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TIGARD
City of Tigard
September 17,2018
Four Seasons Heating&Air Conditioning
Attn: Christina Riggs
1005 Industrial Parkway
Newberg, OR 97132
Re: Permit No. MEC2018-00630
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 11620 SW Bull Mountain Rd
Project Name: Barnes
Job No.: N/A
Refund Method: ® Check#229744 in the amount of$83.78.
❑ Credit card "return"receipt in the amount of$
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 customer cancelled the job. Refund 80%of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
22")Pgrte,
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
II NI
City of Tigard
T I 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: Four Seasons Heating&Air DATE: 9/10/2018
Conditioning
1005 Industrial Parkway
Newberg, OR 97132 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 418891 Case#: MEC2018-00630
Date: 8/13/2018 Address/Parcel: 11620 SW Bull Mountain Rd
Pay Method: CreditCard Project Name: Barnes
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees.
MSO,Ats . ;sw �
Mechanical Permit 230-0000-43102 $74.80
12%State Surchar.e 100-0000-24001 8.98
TOTAL REFUND: $83.78
APPROVALS: SIG
• •
/S ATE:
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
Case Refund Processed: I Date: /t/i? By: I
I:\Building\Refunds\RefundRequest.doc x 09/01/2010