Permit Support Document (62) 9/(c) 4-0o0------ , ,....,_, 7-"..1‘
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT r n,
Request for Permit Action
T l(;,A I:f) 13125 SW Hall Blvd •Tigard, Oregon 97223 . 503-718-2439•w w.ti t , ,i ' _ ,
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TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertraits@tigard-or.gov
FROM: ❑ Owner ►- Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) fJL �'{`"/j ( et.,,,-bio L c„ , F ' (%
Mailing Address: /5[P t 'NU ' 'AR
City/State/Zip: \I -0-.
Phone No.: 3a4 - L1 g
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 #: ELL Fs---W61-5(
Site Address or Parcel#: 102 0S ' kj. 3 r ( tli kk ed. t66('
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Project Name: c4/\`Y( Apr\
Subdivision Name: ASa Lot#:
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Signature: (7?„.1)4.A.„, 4 ,4J
.� Date: 4?-S-
Print Name: ,e.' e4 ...,r t v 1 El / t le...,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONIA-
Route to Sys Admin: Date By Route to Records: Date `//s /`1 By,^'”'
Refund Processed: Date 9/4// y_Invoice Processed: Date By
Permit Canceled: Date /� By� --'/ Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 23 4.duc
III �1
TIGARD
City of Tigard
September 17,2018
Five Star Electric Inc.
Attn: Becca Sinner
756 SW Bailey Ave
Hillsboro, OR 97123
Re: Permit No. ELC2018-00451
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 10205 SW Washington Square Rd
Project Name: Thirsty lion
Job No.: N/A
Refund Method: ® Check#229743 in the amount of$116.82.
❑ Credit card "return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as scope of work changed and only a minor label
was required. Refund 80% of permit fees.
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 • www.tigard-or.gov
IN
s ~ City of Tigard
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: Five Star Electric Inc. DATE: 9/10/2018
756 SW Bailey Ave.
Hillsboro, OR 97123 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 418221 Case#: ELC2018-00451
Date: 7/5/2018 Address/Parcel: 10205 SW Washington Square
Rd
Pay Method: CreditCard Project Name: Thirsty Lion
EXPLANATION: Per applicant's request as scope of work changed resulting in only a minor label
required. Refund 80% of permit fees.
d
't E i i tl 6 9 $ i R i
Electrical Permit 220-0000-43103 $104.30
12%State Surchar•e 100-0000-24001 12.52
TOTAL REFUND: $116.82
APPROVALS: SIGN U' S/DATE:
•
If under$5,000 Professional Staff " 4
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
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Case Refund Processed: Date: �f//2/9 By:
i� �
I:\Building\Refunds\RefundRequest.doc x 09/01/2010