Permit Support Document City of Tigard and • COMMUNITY DEVELOPMENT DEPARTMEN 0 i 0Re quest for Permit Action on /e/3/2/ ,e0
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 RCity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
VCANCEL/VOID 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#: RU P Z a2\- U(YZ 3L(
Site Address or Parcel#: —1$50 cj c.- ork vvio_ '•
Project Name: (o 5 ) 11),t- I \ Mr\e vJ e r ca
Subdivision Name: Lot#:
EXPLANATION: S\nrti kt) '-c u ueer, cxeckVA, a0 Si&-
WcyrV tie c rn \- S E S i T Z-f 2/—6'O/
Signature: Date: /21`30`7-A
Print Name: kNpb v ay't)e j(
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• Not more than 80°o of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80°'o 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/B/3 Z./ By,� '
Refund Processed: Date /V By Invoice Processed: Date By
Permit Canceled: Date 7 W2./ By/7L V Parcel Tag Added: Date By
I:\Building\Forms\ReeernritAction_20 8.doc