Permit Support Document voiD
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JUL 2019
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= y Request for Permit Action ���'� '� �
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T I G A R D 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
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: E Owner ❑ Applicant 14 Contractor ❑ City Staff
Check(V)one
REFUND OR Name: lib
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INVOICE TO: (Business or Individual) c‘ c^ � 1 1�C i -4- C li
Mailing Address: 5E30 'Or -fC1 P V(
City/State/Zip: S'I `Y 1 DR 0 V7 02-7
Phone No.: -_ 7610-2,,, -
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
[V- CANCEL/VOID PERMIT APPLICATION.
kr- REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
[1 INVOICE FOR FEES DUE (attach case fee schedule rV
and provide explanation below).
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Permit#: m e EACed VI - Lt 5 J
Site Address or Parcel#: \.* \1 0 LA_) LJCV\A 5-L,
Project Name:
Subdivision Name: Lot#;
EXPLANATION: C) E.Lne e r LT\I 4�C.m
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Signature: Date: 1 J ] 11ci
Print Name: LI u r be-r-
\X'NE �—'A3�-
Refund Policy t'L�� . ��
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 4 2 71/41--, By
Refund Processed: Date c73 /f By i/ —. Invoice Processed: Date By
Permit Canceled: Date.1%2- /j ByZiy" Parcel Tag Added: Date By
I:\Building\Forms\RegPennitAction_20 18.doc