Permit \I „,,,,,,() RECEIVED
�o �ECECity of Tigard • COMMUNITY I)l l , .)P;rN'1' DEPARTMENT UN q 4 ZUZi
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INI2 Request for Permit Action CITY pFTIGARD
r IC,A It I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www t ,t(i0VISlON
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(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 'P) .A cT L.-C._
Mailing Address: j 2_61> KjE E ye.f- r t en k...s.)..,'y 1 S 709
City/State/Zip: lr\. \S\bro1 C),(z___. 0C 12H
Phone No.: j Z- (.(7 C_. 2:2-2 -
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: ,l j{ ') C>2_` — CC)it-1 1
Site Address or Parcel#: 8 SO (_,,,j �F,,,c,*ytic v:\
Project Name: Crof r-> g•--9--- R C 0-1 C')C1
Subdivision Name: Lot#:
EXPLANATION: \ync 0Y-f-ec -- \�\ e\ �� c 7I
C..
Signature: ,� Date: 6,/1I )?_t
Print Name: a net vra Rc.,,,4-,-
.Re fund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date /#I/J?/ By Route to Records: Date er 6 / B
Refund Processed: Date N By (f Invoice Processed: Date / By
Permit Canceled: Date ,./A/7.1 By C) Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1205 8.doc