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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#: i 6f EXPLANATION: A- yyv ( \CA e\ WL)S %e() �rcX ( A i r\stf An Wtl� A c x1 � i- an /� re re n� trm tk IS VQttacrta b.cif6A Ali) i?,6 ,"cn r-- /4Vr6E7 7a / /' ?2 t 1.f-i 0. 7,7-/ Pe , !/,'''.'. �I 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review eff 1ort .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', i 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 r 1:\Building\IForms\ItcyPcrmitAction_i 518.doc I, 1,,