Permit Support Document (2) V , / I �. RECEIVED t
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City of Tigard • COMMUNITY DEVELOPMEN't I r'A I E ' SEP 0 L 2021
Request for Permit ActionIN
CITY OF TIGARD
q BUILDING DIVISION
I I G A R 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 0 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business of Individual) Caliber Plumbing & Mechanical Inc
Mailing Address: 2615 NW St Helens Rd
City/State/Zip: Portland OR 97210
Phone No.: 503-206-7591
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
FA 1 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#: MEC2021-00674
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Site Address or Parcel#: 12680 SW Walnut St 1
Project Name: PCC Writers House
Subdivision Name: Lot #:
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EXPLANATION: This permit was already acquired on permit number MEC2021-00589. This is a duplicate.
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Signature: ( Date: September 2, 2021
Print Name: Ernie Beasley
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Refund Policy 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• Not more than 80%of the application or plan review fce when an application is withdrawn or canceled before review effort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. III
3. Please allow 3-4 weeks for processing refund requests. l _ 3
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FOR OFFICE USE ONLY 1
Route to Sys Admin: Date By Route to Records: Date 7 � By 4.1/ I
Refund Processed: Date 7,7z,/ .By O Invoice Processed: Date 7 ByPermit Canceled: Date '� By Parcel Tag Added: Date By iI:\Building\Forms\RegPermitAction_ N.doe