Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1 n
.114
Request for Permit Action q/92, d '
T l G A R II 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
REGElvtU
TO: CITY OF TIGARD AUG 1 9 1021
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 CITY OF TIGARD
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertdommoN
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(:heck(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: ! AO 1`OU�0,4-/j
Site Address or Parcel#: 7 g ce) ST J f 0A itkilexe
Project Name: COS te-C,
Subdivision Name: Lot#:
EXPLANATION: e te f-r-( /1CGta,t! Cul fie 714 < G!�
e((,(: S S4 d-( hwc.- Lr,-a t ir,t new MGtS A ekt
5/ te-t3 .
Signature: Date: fIrn /21
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFJCE USE ONLY
Route to Sys Admin: Date 8(I 1 / By /" 'oute to Records: Date �/ By,1-I 0
Refund Processed: Date ,v7.4 By a Invoice Processed: Date By
Permit Canceled: Date 9/j .�—/ By >1 e Parcel Tag Added: Date By
I:ABuilding\Forms\RegPermitAction_1_051 .doc