Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \!
11 111 NI Request for Permit Action 9 72 4-0
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T I „\1?r i 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 TigardBuildingPernuts@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(V)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).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: BUP2020-00194
Site Address or Parcel#: 13815 SW Pacific Hwy, 10
Project Name: Dominos Pizza
Subdivision Name: Lot#:
EXPLANATION: A commercial building permit(BUP) was created instead of a commercial
mechanical permit (MEC) MEC202o—o( 6(0 5j
Signature: Date: 08/27/2020
Print Name: Eggie aldonado
Refund Policy
1. The city's Community De opment Director,Building Official or City Engineer may authorize the refund of:
• Any fee which w 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 9 Z 2- '20 t
Refund Processed: Date.01//4- By�Q(7 Invoice Processed: Date By
Permit Canceled: Date /y f� By.��..- Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12051 .doc