Permit VOID
City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT
_ Request for Permit Action T I G A R l) 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(V)one
UND OR Name:
INVOICE Tom. (Business or Individual)
Mailing Addre .
City/State/Zi •
one No.:
PLE E TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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#: M cT )- oe)2l 3
Site Address or Parcel #: 13(D0 q sou j 2 I.f A V��
Project Name: ,SA. I 2/sr Czn-Nefis
Subdivision Name: Lot#:
EXPLANATION: ACC( e,&, P-Q,D C)4fle/4- refrtgr.
SCE '-ir 7 °u — O a,--7
Signature: Date: 212 /
Print Name: /t j j( J g �q b S1"f
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 / � B ,Ito'
Refund Processed: Date /✓ 4-- By 42 D Invoice Processed: Date By
Permit Canceled: Date 7 'L/y. By/� Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_205I .doc !!