Permit Support Document (2) RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
1111
Re uest for Permit Action Nov 4019
q CITY OF TIGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-c0.104D/NG DIVISION
TO: CITY OF TIGARD V
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 l7/C/
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-orr.gcv
FROM: (l Owner n Applicant RI Contractor n City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: -24 qi ruk. r
City/State/Zip: �-eq .� .e V de---
Phone No.: 3 1Th 4.L 12 LI(
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
E INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: eLIZ 2 d (Gj'.:- U 2 9 C6
Site Address or Parcel #: 7 ) SLR i-- vn pd_vv-1
Project Name: rY\t 4C,- 17A
� vl l`ENC a 1 (VI CP �.�✓1
Subdivision Name: Lot #:
EXPLANATION: pt.),r&v-ii � ,e5 5 4-41-v— S��
Signature:' </V-\C_ Date: \ ( 1a
Print Name: ci,t, , O\c,VY1 t 1 f
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. ` CZl _ /"U
. CI) C
est. ..J-z) e 4, /-
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date V7 -./ B y �'✓
Refund Processed: Date,//f.7 f j ( Invoice Processed: Date By
Permit Canceled: Date I/fp/'?-o By./,/ — Parcel Tag Added: Date By
I:\Building\Forms\Re q P e rm i to c t i o nL'120 gz18.d o c