Permit Support Document (2) RFCEP
_Iri,.
w FEB 1 8 2020
City of Tigard 0 COMMUNITY DEVELOPMENT DEPARTMENT
74
BUI DING DIVISION
i
Request for Permit Acton
u i u,A R D 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD V 0 I y
Building Division 3 `v
13125 SW Hall Blvd.,Tigard,OR 97223 3 /20�7
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant 421 Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) i -n" I /
-
Mailing Address: .--7 O
� q 5 ki C kf("L S C
City/State/Zip: joaux r'1-ov- _ Of__ Choc
Phone No.: N j(� 14-(e q 7�L(
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
g, CANCEL/VOID PERMIT APPLICATION.
nREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: -FL 2_ 0`9 00 t -jjj
Site Address or Parcel#: 1''7---7 06 SW O kG t,\ C,/A 6:2--
Project Name: `T ras\5(�o rp-,rN- !- ,\ 4 on �--L-
Subdivision Name: C Lot#:
EXPLANATION: 0 LA$ -v.ynyi- h •ou A 0 at .-( --e
aCON4r ._
Signature: ' tAnL.41 N.„ Date: 2 l(y I Z 0
Print Name: rN orlc-m(Lf
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. /7 0 /2.e,, G-0 3G• 4ti
/,, 0-0 ' /L/• V 0 '
/ /77J /3y' 'to 3, 0
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 9 3 Z.j By
Refund Processed: Dated/zo/ze By %Y ' Invoice Processed: Date By
Permit Canceled: Date /3/ 120 By -.. arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 1 0518.doc