Permit Support Document RECEIVED
VOID
JUL 11 2017
7EL(p 7
City of Tigard o COMMUNITY DEVELOPMENT DEPARTMENT CITY OFTIGARD
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Request for Permit ActionvnMING DIVISION
I-l c;A R a 13125 SW Hall Blvd. •Tigard,Oregon 97223. 503-718-2439 • www.tigard or,gcn'
TO: CITY OF TIGARD
Building Division
13125 SW I Iall Blvd.,Tigard,OR 97223
Phone: 503-718.2439� Fax: 503-598-1960 ., rigardBuildingPermits(a�tigard-or.gov
FROM: ❑ f Owner { Applicant ❑ Contractor ❑ City Staff
Check(✓)one i? `
REFUND OR Name:
INVOICE TO: (Business or lndividaui) / !liVtfCAIL U,Li
Mailing Address:
ra
City/State/Zip: UdtY\1YOi tq(y
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
igCANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES(attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FARS DUE(attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: PLM (o—oU 9.9 5 (/PuLiAt511.1Q, 'd(rt. cy—i Lri—'mES
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot#:
EXPLANATION:
Signature: YlA) Date:ayk t go '
Print Name: 12.(11;kda te
,
Befund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fcc 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 fcc 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.
Route to Sys Admit: Date By Route to Records: Date ,By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: „ Date By
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