Permit Support Document RECEIVED
ED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCT _ 6 2021
II Ir
Request for Permit Action CITY OF TIGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wv w.tig'� . DIVISION
TO: CITY OF TIGARD O.
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 ivyZ 3�Z�
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 7 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKFCTION FOR THE ITEMS) CHECKED (1):
CANOE OID PERMIT APPLICATION.
R UND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attachcase fee schedule and provide explanation below).
Permit#: !I-C-02c2 /—t.S7v7
Site Address or Parcel#: I I?cv Sk/ /Atl/ ar.,./
Project Name:
Subdivision Name: �� Lot#:
EXPLANATION: f--‘d`•'l4.1r,,e-,Gxw ejretfyi u l rf141/
L - r
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Signature: Date: /ol(p72..�
Print Name: /1•e- 41'6r
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 4c; 6k I By 'j/ Route to Records: Date 9p 23 p/ B
Refund Processed: Date il/ By a/ c) Invoice Processed: Date By
Permit Canceled: Date foh.3 2j By,10 Parcel Tag Added: Date By
I:A Building\Forms\RegPermitAction_1f0518.dsc