Loading...
Permit 1 v City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I 0 'PI Request for Permit Action T,t„\1. l) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 1 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 'P E OR Name: INVOICE TO: Individual) Mailing Address: City/Scat Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ,ErCANCEL/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#: SW W,2 o 2 \ - Ca a2.. Site Address or Parcel#: 1 29 2 Q C3A3 (A.)4riLIV cT 5-1-- Project Name: f'h/(, e12- PhD sW2 Subdivision Name: WA Lot#: /1/4)/A EXPLANATION: p c_c_i Oer"f7a U.,)1 GQe A Tom) -pie. PP.efiel I Jr r}c.- e S A N I K a> c Fe I r- ,4�y vN Z.. cc -2d 2(-CO6 i o /A 9.25' .s i =✓fl c.,c./ L?— Signature: __/'rT Date: i/ /1&12/ Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 By Route to Records: Date A/� By JO Refund Processed: Date )` By4 Invoice Processed: Date / By Permit Canceled: Date /6/2 By, p) Parcel Tag Added: Date By I:\Building\Forms\RegPer itAction_ 20518.doc