Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV0 :q
= Request for Permit Action /%//ti st %
, ; ,, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov Add .
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 ity Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone N •
/PLEASE*' ACTION FOR THE ITEM(S) CHECKED (1):
CANC OID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 4,e1O/3 1O0/ 7
Site Address or Parcel#: q S? /h"✓& <37-,
Project Name: 7aeigietzvu i�4,,,1 e.. ,,,4"- ,sr,,,
Subdivision Name: -- Lot #: —EXPLANATION: /`l„,, , .. 6.,,„.3 Ai,,,,- 7.,r -q 4 r- a rc.-71-.,.e,! ey_tv,,S70 .
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Signature: eg.-,t,./��� Date: io/;/�J')
Print Name: �,-22.,r,,(...e.-.
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 fd/, , i By Route to Records: Date,i/y3/2/ By ,,(00
Refund Processed: Date N/ By Invoice Processed: Date By
Permit Canceled: Date / ////Z/ Byg.y Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 518.doc