Permit Support Document (2) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT R EC E I VED
■ Request for Permit Action
DEC 2019 -
FIG A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigar GrtI� �rG TIGARD
.R I,� DIVISION
TO: CITY OF TIGARD V 0 1
Building Division //f0/2-e, 7-o .8
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
Check(1)one
REFUND OR Name: /� /�� �� T��
INVOICE TO: (Business or Individual) 1 1) K. ` c ee 12�`l Crok YI �ep.,) . .4 Il.��.
Mailing Address: 2) ) 1- t
City/State/Zip: 140 (� �-� ��� � C(`�,'"y 4,t/tt,6'
Phone No.: 7 7D-772-31-/Ob Ai 6 5u t
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#: EZZ 2n - c ��ej
Site Address or Parcel#: (1102 514 t 4'�t �X CC__'Rea 'Rd.
Project Name: 2 q AFL . ..i'] gCcXo ReF SY 1
Subdivision Name: Lot#:
EXPLANATION: P(� �/l�`�" c S calftIe e,C7\ . � ? i�►j be.
(tone. 3
Signature: ,4 0 yi Ak Date: 12/r l 71q
Print Name: ! k 4• zsp,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
5,6 I /t _ 7y, 5y .- / . ?-y
c • 7r ' s. `7
- -. 3 /,;./. - 5.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 9/7 Z/ : C/•
Refund Processed: _ Date ///7/7t'? B Invoice Processed: Date By
Permit Canceled: Date f id 2c,Ze- B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction051doc