Permit (9) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
!PI N Request for Permit Action
Tic;,1 It l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD V
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov
FROM: ❑ Owner V Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Polygon Homes WLH LLC
Mailing Address: 703 Broadway St., Ste 510
City/State/Zip: Vancouver, WA 98660
Phone No.: 360-695-7700
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
V 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#: MST2019-00314 I S 2S) \—o o 2 3
Site Address or Parcel#: 16595 Sunshine Coast St
Project Name: Polygon at Roshak Ridge
Subdivision Name: Polygon at Roshak Ridge Lot#: 143
EXPLANATION: Plan renamed and updated
Signature: %gn-� Date: 1/6/2021
Print Name: Tonja Morris
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 //Q .2./ By b /
Refund Processed: Date By Invoice Processed: Date 0414( By 4'kWt'
Permit Canceled: Date /�gZ/ By/ Parcel Tag Added: Date By
I:\Building\Forms\ReqPermitAction_20518.doc