Permit (10) IN
City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT' .../ r),.....,, ,,, j D.
: . Request for Permit Action
1 I G A It I) 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: ❑ 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 (✓):
VI 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#: MST2019-00322 ISLASQ:2.0\c\ - o a 2 LA C.
Site Address or Parcel #: 16581 Sunshine Coast St
Project Name: Polygon at Roshak Ridge
Subdivision Name: Polygon at Roshak Ridge Lot#: 144
EXPLANATION: Plan renamed and updated
Signature: /6yti-- 4.44i,
Date: 1/6/2021
Print Name: Tonja M ns
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ESE ONLY
Route to Sys Admin: Date By Route to Records: Date / /9 Z/ By I
Refund Processed: Date By Invoice Processed: Date ///e//jam By Mr
Permit Canceled: Date/,/9/2/ By /IV Parcel Tag Added: Date By
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