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Permit Support Document M City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT �� ■ n I Request for Permit Action 8 L .ze, .6,o TIGARD 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 TigardBuildingPertnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: _. PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): �NCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedulelfd provide explanation below). ©0. o`3 Permit#: / ' O&)- 4 Site Address or Parcel#: //S S— 52.) AG,-Xt / Project Name: t,,.e' /P�„..2...--- ' Subdivision Name: -__.---- Lot#: ' EXPLANATION: p /1s�r i f Tir 7l'7ne_ e., 4. .,} z . 71-,... 75. ..1(4r',77 '.-Lv 74.1ir e it. Signature: Date: FA)%j Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 Admin: Date 6 ,s jz/ By d.;; Route to Records: Date . By<to Refund Processed: Date /V/e9- By 46 Invoice Processed: Date By Permit Canceled: Date fyuy By.; 1O Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_1 518.doc