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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 co 7�rL✓2 d.0-0 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 art 717iNfe. et" Ur, 7 4710 ` y ( JJ/?- o -GAJ/yam..__ 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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