ADJ2020-00012 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V /�
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Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.iigard-or_gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPemiits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(-')one
REFUND OR Name:
INVOICE TO: (Business or Individu4
Mailing Address:
City/State/Zip:
Phone No.:
PLE ACTION FOR THE ITEM(S) CHECKED
CANCEL/ OID PERMIT APPLICATION.
REF PERMIT FEES (attach copy of original receipt and provide explanation below).
NVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ADJ2020-00012
Site Address or Parcel#: 6960 SW Clinton St
Project Name: Clinton Street Mixed Use
Subdivision Name: Lot #:
EXPLANATION: In the Tigard Tirangle,multiple adjustments are allowed under one case.
See AD12020-00010
Signature: &V12 ye& Date: 5/13/20
Print Name: Agnes Lindor
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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°14 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.
• ' OFFICE USE ONLY
Route to S s Admin: Date 1.c Route to Records: Date / I B
Refund Processed: Date By Invoice Processed: Date B
Permit Canceled: Date 31112-., By Parcel Tag Added: Date B
1:\Building\Forms\RegPermitAction_7 5 B.doc