Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 3 0 2019
SO
)14 . , Re
quest for Permit Action CITY OF TIGARD
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1.i) 13125 SW Hall Blvd. •Tigard,Oregon 97223. 503-718-2439 • ww.tig dloogov DIVISION
TO: CITY OF TIGARD 0 I D
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 fr p-- /f ex/
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant `A Contractor 0 City Staff
Check(✓)one
REFUND OR Name:INVOICE TO: (Business or Individual) L;.Cel/ej,ce Pikfrid)/11'sy .LLC.
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Mailing Address: 7 /3 �' h us Ape
City/State/Zip: )Pq Vf y1 n y, 0 fe,
Phone No.: 9 7 0(D t
PLEASE TAKE ACTION FOR THE ITEM(S)CHECKED (1):
rie
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CF.T,/VOID PERMIT APPLICATION.
ROUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE(attach casec fee schedule and provide explanation below).
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Permit#: 20/9 - 6)03 3
Site Address or Parcel#: ///OO vV g.),1 11i'.it
Project Name: Mu e5;clio, --ha I
Subdivision Name: Lot#:
LANATIOLN: C. j--
a i SO M/` r! 73
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Signature: p4.4. G� Date: L-30--f%�
Print Name: P 1 (Aa olio
Itefimd 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date ( 7. .-j By
Refund Processed: Dates//p By 41/ Invoice Processed: Date By
Permit Canceled; Date 4/4,..jj9 By .• v Parcel Tag Added: Date By
I:\Budding\Forms\ReVermitActiorLl 51 .doe