Permit Support Document t
City of Tigard • COMMUNITY DEVELOPMENT DEPARTME Tip
l�c l. Request for Permit Action F
iZj9/ry 41(7,
T I t.;A n 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 TigardBuildingPemlits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® 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 #: ELC2020-00442
Site Address or Parcel#: 15209 SW Summerview Dr.
Project Name: Villanueva
Subdivision Name: Lot#:
EXPLANATION: Permit created in error S E i`is 7-20 Zn - 00 2-3-9.
Signature: Date: 06-3/-2020
Print Name: Eggie Mal&nado
Refund Policy
1. The city's Community Devel. ent Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80°/u of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date/2''/f j By ,/,7
Refund Processed: Date AO- By A?d Invoice Processed: Date By
Permit Canceled: Date /Lq/yam Bydc Parcel Tag Added: Date By
I:\Building\Forms\RegPemtitAction_12 51$.doc