Permit Support Document V ID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0149/J 744—
No Request for Permit Action ^'�f
T 1 ci A R D 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) LEIJNA2 1 )Li) />JC.
Mailing Address: /1 C07 IJ E- 99 freeeT" 're. 070
City/State/Zip: VAI rJ Co J Z , LOPr (3 q LQ S of
Phone No.: '�(oo-oZ58— 790a
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKEDR., (✓):
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 can
Permit#: "1 f5fdtei 5 O'6 t.,D,R, lU 15-ea 144,
Site Address or Parcel#: LA2-I
Project Name: tA., Ei-,Tr-rf Le,-
Subdivision Name: t:)j PV Ys. E,r.4Te S Lot#:
EXPLANATION: e> 12-,-C1-c -TIE) tT D I >rGt 2fAST- ) 7 Pt",
IIJJoic ft_ IJp/L. 1'C —P-\ JtftJ (e-E. `emu?oN.tTWvL ib .
fe s It f3 itv a 5-1)6,a s.21.4-44.),eao/5 —o0/5-V
Signature: C,1,GQeL ki Date: I I 1 i(,f t S
Print Name: `T£ a 6, t. , Prb,at M ,K
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admire: Date f t / /S :4 Route to Records: Date/ A2 /s B
Refund Processed: Date itJ/fl- B ,%/ Invoice Processed: Date% By
Permit Canceled: Date /?//pi/$ By !,r. arcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_09"2314.doc