Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
I. r Request for Permit Action
1 I l;,‘k I) 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: ❑ Owner ❑ Applicant Contractor ❑ City Staff
Check(✓)one /`
REFUND OR Namc: f5+INVOICE TO: (Business or Individual) titattr
Mailing Address: Un t 5 ilov-th ere V pKwl ,S CIo to
City/State/Zip: PlotAldt t vof 6y31)t1
Phone No.: 4'LC-((ii .1P911
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). i
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). S
Permit#:
Pm 7,D-2.4--001 12'
Site Address or Parcel #: 1 OC 1S ctj CJ r v-wk,\ I m(,ova 1 pg. cj1 ,2.
Project Name: l
Subdivision Name: Lot#:
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EXPLANATION: A- yyv ( \CA e\ WL)S %e() �rcX ( A i r\stf An
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Signature: f'I��q�t i'.4 Date: 05 O •i 1' -1_4
Print Name: H a[1n(;t. M valet irl4
J.e(jtd Policy 1 1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review eff 1ort .
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.
II',
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Route to Sys Admin: Date By Route to Records: Date .2? 3j By
Refund Processed: Date/�f By 0 Invoice Processed: Date By di
Permit Canceled: Date�/�"` By Parcel Tag Added: Date By
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1:\Building\IForms\ItcyPcrmitAction_i 518.doc I,
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