PFI2019-00434 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0
Request for Permit Action / / de
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 []'City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
✓� CANCF,I /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#: PrZ2bl1 -tV't3H
Site Address or Parcel #: //Q yp c5t✓ 6 ' ' Pkit
Project Name: ieo,( ce' i n-,I ?Trail OIQ g7223
Subdivision Name: Lot #:
EXPLANATION: /a1£iiae.rmi/- whirl fi,-- e i cerce_L im
, rmil 414.1 never eaglet #'Ws..J I20,L heeded
NO Te vrrrd
Signature: j„� 7/yrfj< Date: 6 h 7/242I
Print Name: ogr,G key
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 '/ By Route to Records: Date( t 7 L/ By,�/
Refund Processed: Date N By Invoice Processed: Date By
Permit Canceled: Date /L/ B{1O • Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_1 0518.doc