Permit (11) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V Q
■ Request •for Permit Action
, ,;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 ® 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 (✓):
40 CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
I I INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MST2019-00453 I LA)2_2. k - 00 322-
4
Site Address or Parcel #: 14320 SW 165th Ave
Project Name: Polygon at Roshak Ridge
Subdivision Name: Polygon at Roshak Ridge Lot#: 172
EXPLANATION: Plan renamed and updated
Signature: % Cr,722G2 Date: 1/6/2021
Print Name: Tonj. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 / By p7
Refund Processed: Date By Invoice Processed: Date 24 Bylili
Permit Canceled: Date l/.2 # 2.l By / Parcel Tag Added: Date By
I:\Building\Forms\ReqPermitAction_205 doc