Permit Support Document inCity of Tigard 0 COMMUNITY DEVELOPMENT DEPARTMENT V 0 1
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IN
Request for Permit Action f/g,/�/
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov . 0
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 D ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
ill10EL/VOID PERMIT APPLICATION.
0 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#: / 9-d&-(,U,j U 7/cs"/2d11'J --0 6( ?'et
Site Address or Parcel#: /$7(6 3�,/ 3l-Stlilt-
Project Name: at.kci/Va LA at
Subdivision Name: . — Lot#:
EXPLANATION: ,Z,c, ,• C, �,, -� /�•,i CP.,) Vi, SGc.JG✓' Lcdv,/'te'76).2
S E Az-, &AO - rpf e s-,� i 2O
Signature: e-e-_ , ,' Date: 7/0lac)
Print Name: g,7de, �� ,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 OFFICE USE ONLY
Route to Sys Admin: Date 5"J By 4e, 7-) Route to Records: Date `;27 By .' /-
Refund Processed: Date /V By, U Invoice Processed: Date ' By
Permit Canceled: Date / By.4..d Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 0518. oc