Permit Support Document (2) T1 RECEIVED
IllCity Of Tigard ' COIvIMUNI TY DEVELOPMENT DEPARTMENT
. ��
Request for Permit Action Pa 2 8 2020
y®F?IGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-oc • LNG DIVISION
TO: CITY OF TIGARD V
Building Division 0 1 0
13125 SW Hall Blvd.,Tigard,OR 97223 M` 1/2e)
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard--or.gov
FROM: ❑ Owner ❑ Applicant A Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) PrbT C.C.
Mailing Address: /2 Q421 suo Cy(u S . 1
City/State/Zip: G j? a UQ( .V Jv De_ Ch 0e)q
Phone No.: 6''3 L.L.Lq -7 4
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#: T& 202 0 — UO d"3
Site Address or Parcel #: I y c L,e' '?L ' ✓. ) to 0
Project Name:. ./r1 k t e'Y'',._ v v-'( Se^,V( c__.p„
Subdivision Name: .C23-. UU Cf PGt/-4--'4-t tir\ Pl ork Lot#:
EXPLANATION: �kk--, 0 \r,- ( Li L r\c _ .`
Signature: ----�G trrGrn � \_ Date: 71 Zq I zd
Print Name: t rN ` rn C in,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. ! . G'v
9', o'p - 7. 24
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date `1/3 2./ B ./r
Refund Processed: Date s /y,1/20 B r// Invoice Processed: Date By
2/
Permit Canceled: Date /.ze, /j,I By / Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAcrion_126518.d'oc By