Permit Support Document (2) REGB'J
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAR 1 Z020
a Request for CITY of_�u(AsD
q o Permit Actionu��.���vCu�vwsic �
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 '3 ��/
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ' Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Le_
Mailing Address: -'16-1 q q( ( �S
City/State/Zip: �2961tLe-r 6 (Z U
Phone No.: Cj c 14 LA —7
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#: L U (q _ U01'1•
Site Address or Parcel #: 2'j7 St41I k :b
Project Name: \ZL t VV.j.� `
Subdivision Name: CG(Av`C (� l J( (AC(.t j. L"ot#: 2 1- 4/ "I
EXPLANATION: C (7 Gl,,r\C-C
Signature:: 4-- Date: '1\---7)\ U
Print Name: � VYltn�
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 7/3 "2 Le
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Refund Processed: Date 312 'k1 By 07 Invoice Processed: Date / By
Permit Canceled: Date ? .70/2e) By I Parcel Tag Added: Date By
\Building\Forms\ReciPermitAction_120518.doc