Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 fl
NI Request for Permit Action 1/€3.7/. /
1-1 6 A R 1) 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 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 (1):
CANCEL/VOID PERMIT APPLICATION.
❑ 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#: MiVTJdV—r)(1 ` S
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Site Address or Parcel #: /576c) t•r
Project Name: L/ kaj Ul
Subdivision Name: Lot#:
EXPLANATION: _�'�r14"'),7 �r�-a, d/ ,w Gvr�✓_ -�lti�v�}1/Y-rJ15?a�_I
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Signature: Cr Date: 61„i
Print Name: ,d� dp,J /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 S" a j-t) By ,T Route to Records: Date 41/ 7 By ✓r
Refund Processed: Date ,i/ By, ) I Invoice Processed: Date / By
Permit Canceled: Date ?-7/>/ By.& d Parcel Tag Added: I Date By
I:\Building\Forms\RegPermitAction_1 0518. oc