Permit VOID
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT -I/Lk/Z/
)1 I N Request for Permit Action �y ��
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T j(,,\jt t) 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: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: 0 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):
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#: BU P2021-00100
Site Address or Parcel#: 14125 SW MITCHELL CT
Project Name: HINDMAN
Subdivision Name: Lot#:
EXPLANATION: BUP2021-00100 WAS CREATED IN ERROR, REPLACED WITH MST2021-00168
Signature: Date: 04/28/2021
Print Name: EGGI ALDONADO
Refund Policy
1. The city's Community D: elopment 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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
Route to Sys Admin: Date By Route to Records: Date? B ,/ )
Refund Processed: Date /1 ie" By d Invoice Processed: Date By
Permit Canceled: Date tlkiit\ By vw Parcel Tag Added: Date By
I:\Building\Forms\ReyPermitAction_120518.doc