Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
' _ Request for Permit Action 0, i
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TIGARD 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: 503-718-2439g g Permits@ � r.gov
Fax: 503-598-1960 Ti ardBuildin ti d- r. ov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
R".ANCEL/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#: 5Z„ .016n—(Jd 1(16 1
Site Address or Parcel#: l STGf S J j -77P421/ 0
Project Name: iliefir att.b 1O✓- l^7�V
Subdivision Name: Lot #:
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Signature: Date:ame: 4 [ i7
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 1
Route to Sys Admin: Date 8 3 ii By 0 'oute to Records: Date ff' 1p�?/ By de
Refund Processed: Date fit// ' By 4?a Invoice Processed: Date By
Permit Canceled: Date,1/6/2.../ By.eui d Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc