Permit Support Document (58) / n .
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City of Tigard • (•()NtMituNrry 1)1,v1:1()I,Nti:N-1-t)EEP.\R-t-lli:NT /C9 ler" .
it* Request for Permit Action
t ,,., , s, 13125 SW Hall Blvd. •Tigard,Oregon 97223.503-718-2439 ► ve‘)A, ,ttl;.tt-tl , 1 0. CI
TO: CITY OF TIGARC T 2 2018
I.I
Building Division CI-IUy OF r,GAp
13125 SW Hall Blvd.,Tigard,OR 97223 Bt11L,.D1,NGiViSi Ni
Phone: 503-718-2439 Fax: 503-598-1960 TigardBinldingPertnits@tigarcl-or.gov
FROM: ❑ Owner ❑ Applicant 0 Contractor 0 City Staff
(:here{/l one
REFUND OR Name:
INVOICE TO: (Rumness or individual) Northside Electric
Mailing Address: PO Box 12323
City/State/"Lip:` Salem OR; 97309
Phone No.: (503)585-4879
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Q CAA.NCEI./VOID PERIt1IT APPLICATION.
ED REFUND PERMIT FEES(attach copy of original receipt and provide explanation below).
O INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below).
❑ RENIOVE/RF.PLLAACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ELC2418-00673'
Site Address or Parcel#: 9165 SW 70TH AVE.PORTLAND
Project Name 37666 Jeff Walsh
Subdivision Name: Lot#:
EXPLANATION: The scope of work changed on ELC2O18-00673and we did not end up needing the
permit as we did no panel change.A minor label was used for the work done.
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Signature: < Date: i(r/79/l R
Print Name: essica Ensign
Refund Policy
1. `Aloe city's Community l)vveltipmrnt Director,Building t)fiicial or City linginecr may authrxixe the refund of
• :any feu which was erroneously paid or collected.
• Not more than 806ii of the application Or plan review fee when an application is withdrawn or canceled before review effort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 feu issued permits prior to any inspection requests.
2, .til refunds will he returned to the original paver in the Finn of a check via
7US postal service.
3. Pleas e allow 34 weeks icor processing refund requests.
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Route to Sys Adnan: Date Bt Route to Records: Date r/ /7 /9 By
Refund Processed: .[?ate,// / / " B Invoice Processed: Date By
Permit Canceled: Date/e /cf By. ----P heel Tag Added: Date By
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TIGARD
City of Tigard
November 29, 2018
Northside Electric
PO Box 12323
Salem, OR 97309
Re: Permit No. ELC2018-00673
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9165 SW 70th Ave.
Project Name: Walsh
Job No.: N/A
Refund Method: ® Check#230458 in the amount of$90.22.
❑ Credit card"return"receipt in the amount of$
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 a minor label was
used. 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
City Tigard
Ti and
TI c A x„ 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: Northside Electric DATE: 11/16/2018
PO Box 12323
Salem, OR 97309 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 419921 Case#: ELC2018-00673
Date: 10/12/2018 Address/Parcel: 9165 SW 70th Ave
Pay Method: CreditCard Project Name: Walsh
EXPLANATION: Per applicant's request as scope of work changed and minor label was used. Refund
80%of permit fees.
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}w i _ $a ,a.�. �' x ,. '� rn,
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.6511!4'4,4t:,AA $ s a "im
Electrical Permit Fee 220-0000-43103 $80.56
12%State Surchar•e 100-0000-24001 9.66
TOTAL REFUND: $90.22
APPROVALS: SIGNU: S/DATE:
If under$5,000 Professional Staff `ii �I l
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: Date: y7/Z By: 4jam,
I:\Building\Refunds\RefundRequest.doc x 09/01/2010