Permit VOID
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV XX
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Request for Permit Action '�11. is Gik
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard Vl ga G DNIS1Q�'
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 C
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
z0 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#: ,s‘cileao?(- ao0a7
Site Address or Parcel#: l 10696- 4,t //O6'7 ,SZO '77 1 l�
Project Name: G--u ei/ ' - ��G//� 75 1 j '��'�✓�
Subdivision Name: ..--- Lot#:
EXPLANATION: ne. • / f
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Me-el-It s et,t,n' 'ccI-el/Y-14/I '1 1Ie k ve Ivry
Signature: J Date: 7/J�
Print Name: k`/•L l�/kt'& ez•V-
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date 7 ,Z,/ By Route to Records: Date 2i By d
Refund Processed: Date 4//44 By C Invoice Processed: Date By
Permit Canceled: Date er/4'/7r/ B J Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1205t .doc