Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTM F
111,1
Request for Permit Action I
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tjg.ard-or.gov
rkeCEIVEU
TO: CITY OF TIGARD MAR 1 S 2020
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 CITY La= IicaARD
ni�VISION
Phone: 503-718-2439 Fax: 503-598-1960 Ti 49npernuts@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 (✓):
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).
Permit#: L` ,z�j2�j •— )(CoL
Site Address or Parcel #: _/0„2,6,Q SGJ
l
Project Name: Sc-Gy'e/'c�
Subdivision Name: Lot#:
EXPLANATION: 61,Vra7 ' .7G.e) S/c'4-7-
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P vra{r.� f L11- . ' 64 2C C -oodS Y3.
ignature: /4-"J
�KX,k-d Date: 3'�QlPrint Name: u l'� O'cKL�Ge-!!
&Lind 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 j / )J By Route to Records: Date /2 92t> B'. 'C
Refund Processed: Date N ..4- By it ' Invoice Processed: Date By
Permit Canceled: Date et ;„g�j� By t—q Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_l 059 8.doc