Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT DEC 0 5 2019
!INRequest for Permit Action CITY OF TIGARD
BUILDING DIVISION
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD //�%z '
Building Division / I
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: El Owner ❑ Applicant Q Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Lease Crutcher Lewis
Mailing Address: 550 SW 12th Ave
City/State/Zip: Portland, OR 97205
Phone No.: 503-223-0500
PLEASE_TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANC VOID PERMIT APPLICATION.
UND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PLM2017-00080
Site Address or Parcel#: 7350 SW Dartmouth St
Project Name: Triangle Medical Office
Subdivision Name: Lot#:
EXPLANATION: Project went through LUBA and never happened.
Signature: ,/m : / - - Date: 12/5/19
Print Name: Monica Green
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 3 /'1 2,v By .c7&
Refund Processed: Date By 44 Invoice Processed: Date /(o Z By e
Permit Canceled: Date ////p Jze,2:z By •!'• Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12051 doc