MMD2020-00033 City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT_ 0
: " 3I2/ �0
Request for Permit Action /
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 7121, City 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 (1):
ti CANC OID PERMIT APPLICATION.
D PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: g M D uzo- a')D 3
Site Address or Parcel#: 1 C S\A/ W,Ar tO(,
Project Name: Tat I(,j —1-CM
Subdivision Name: Lot#:
EXPLANATION: 1DU? '1 M i 2020- 0001,01
Signature: - Date: l 2 D
Print Name: 18t7'--:00erS(-11,4 r(
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 B Route to Records: Date B
Refund Processed: Date A//.f}- B. IO Invoice Processed: Date By
Permit Canceled: Date 3/,Jyi By4() Parcel Tag Added: Date By
I:\Building\Forms\RegPernitA ction_12051 .doc