Permit Support Document (2) wr ,„
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Ph = Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD VOID
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 /(.`'2/ A�
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ElApplicant ❑ Contractor ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) /�/ �` M y� ML- !� 4) + rE-
Mailing Address: / ' //70 . Z�S,`//Grp
�7 p /�z1
City/State/Zip: 776-4172-6,
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Kai CANCEL/VOID PERMIT APPLICATION.
►e REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
111 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: /3 GC-/� '' C,2Z/•- O.0 'f /
Site Address or Parcel#: 70 .�?.c) l OO '� mice7—
Project Name: l 1/74-7
Subdivision Name: Lot #:
EXPLANATION: / L-'� Ei G0972-6 D r`11-7--&d A-0 (�•L-77 7 t7.S
fir I i /A/ "f.S`770.2--OP-/ — UlJ JS/•
Signature: i��L%r2�•- -�.r�l--� Date: 41 /'7.--�
Print Name: /. /AP.ri- 0,4t/e2
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 9//0 Z_/ By .-•E
Refund Processed: Date '7/4, Z../ Bydd Invoice Processed: Date // By
Permit Canceled: Date f'/I, We)e) Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 518. c