Permit City 0 1
ofTigard • COMMUNITY DEVELOPMENT DEPARTMENT
111 5701
Request for Permit Action
T A R[) 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: ❑ Owner ❑ Applicant n 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 (✓):
• 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#: BUP2020-00234
Site Address or Parcel#: 10615 SW Highland Dr
Project Name: Freeman
Subdivision Name: l,ot#:
EXPLANATION: BUP2020-00234 created in error, replaced with MST2020-00317
Signature: - - i/,/71r Date: 11/12/2020
Print Name: Eggie M. donado
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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
Route to Sys Admin: Date By Route to Records: Date i AeW B
Refund Processed: Date , 'B Invoice Processed: Date By
Permit Canceled: Date 't4 fryi I B • Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518A oc