Permit Support Document Vo
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
II ■
Request for Permit Action 2 zi �v
A r 11 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: El Owner El 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 (1):
F CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 4)/c- /
Site Address or Parcel#: 2.2� Sit) 7 y w E
Project Name: e' 4
Subdivision Name: Lot#:
EXPLANATION: /0e-v-// i A/a " 25TQ. i,) 7 7/
7 y4- / 4L(/r m�% �9 A—a e--t 2..L,A/6.s- `uJ/L 44
�^r7Zr/e / y 3/t> " r
Signature: ��t¢ Date: V/4/2__/
Print Name: L/6")✓.✓"- ll/Ln/ET erf
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 7,6 G/ By fa
Refund Processed: Date N//71— By 46 Invoice Processed: Date By
Permit Canceled: Date Z,!z.../'Z/ By Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_120518.doc