Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V0 1
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Request for Permit Action / /
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • WW-w.tigard-or. ;ov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerniits@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 AKE ACTIO FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
E INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 5l-C.O&D a
Site Address or Parcel#: ? SLJ e-e, Q /a)
Project Name: oaxel , fie..
Subdivision Name: Lot#:
EXPLANATION: / - 421" G cJS 7'7�c ) ,V J r/ S
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Signature: Date: /j>/p-/,stl
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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Route to Sys Admin: Date fd H di By /� 7. Route to Records: Date /Q 23/y/ By ite
Refund Processed: Date A/�/�- By �(J Invoice Processed: Date By
Permit Canceled: Date /p/y,3/yj By 4QQ Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1�0518. oc