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Permit V I :cid City of Tigard • COMMUNITY DEVELOPMENDEPT r MI ECEIVED 711Request for q Permit Action JUN zt T I GA R f7 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • uw v.tigu TO: CITY OF TIGARD t �5"+t1(a�Rp BUILDING DIVISI ON Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner Applicant El Contractor ❑ City Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) p } L-C Mailing Address: g2Q j` AlE E vc rr ,--r en p 1:.,„.s,,i I S\r_ 7 O -( City/State/Zip: t'C- \\5S-..,„,,—r) I (Th & c2C7 1 2_(-1 Phone No.: , C):7. —LA( 26, — 2222 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): .r CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). C INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: SG,1 12,.'2-.C32\ -O() 114 D Site Address or Parcel#: --(g5O sc..) :r--j- „ ; Project Name: ('IO-y{-tio " "v c r...ck R, ,, - ric e• Subdivision Name: Lot#: EXPLANATION: \n r c,r,,-r,-k- \a b c\ n c,,c' `c Signature: �E Date: 0(1,11(4)2_I Print Name: Arnim r c e, ,{,r,. Refund Policy 1. The city's Community Development Director,Building Official or City l ngineer 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 tiby // By Route to Records: Date h Ae Bye Refund Processed: Date WI By © Invoice Processed: Date ' By Permit Canceled: Date ,�/y/2 j By e Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_ 265518. oc