Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I
111 4- Request for Permit Action ////y/7-' a
TIGARD 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 Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEAS CTION FOR THE ITEM(S) CHECKED (1):
CANCEL/ ID PERMIT APPLICATION.
PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: �/„���a�— Doman
Site Address or Parcel#: 5&t) bz-vp
Project Name: S c ,S�c
Subdivision Name: Lot #:
EXPLANATION: r✓ f ,yJ G✓r(J✓. r) ! € j
A //) �s-✓y�^i� 7$Jv c� Ga' i�. 4j ) � op(Ny o pr_syv�r
6�Lr ��) U0�/s'C0.
Signature: "'r' Date: ////Ay/
Print Name: et „' J f��
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.
1 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 // / .j By Route to Records: Datef//y Z/ By,.te Q
Refund Processed: Date 4' By ? Invoice Processed: Date By
Permit Canceled: Date////9oc 2/ By�P Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_T2O518.