Permit Support Document (2) V/ 0
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RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT SEP 0 f' 2021
` Request s t for CITY OF TIGARD
q Permit Action DUILDING DIVISION
TIGARD 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 /R1 Contractor ❑ City Staff
Check(/)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ,Q.) Uea,,1 P . j \ (\)C..,. .
Mailing Address: 15 jG n-, S C'G..
City/State/Zip:
b.eak...1„,2,6cxe04.,. oz. on-ryA
Phone No.: 5.))- (rl ) - i 5 io-7)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
D/ CANCEL/VOID PERMIT APPLICATION.
W 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#: nrs ,` M, _C2()
Site Address or Parcel#: (119 S W Q`' R dose, )v. CAlTd/
Project Name: \Ni\Ncy
Subdivision Name: Lot#:
EXPLANATION: -,tl-S C-(..(CS_V C� ,klYJ (\ a 1
D• 'c C>\\\ k \\ .
Signature: li a� � Date: q/ p--/ a-I
Print Name: I1� I ' I�r /SiTat-t,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. h G v- 1
/Iv .F ' /4e.4, ' 2-4',/4
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date /p ',./ By .!e
Refund Processed: Date V'/7 y/ Byr�t Invoice Processed: Date By
H,
Permit Canceled: Date 4 /,� By , i 7/', Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1_051 doc