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SDR2021-00005
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action 1 TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.go//Z-/ 'w 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 Q 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): © CANCEL/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#: SDR2021-00005 Site Address or Parcel#: 11630 SW Hall Blvd Project Name: Trojan Storage Subdivision Name: V Lot#: EXPLANATION: Created wrong case type. Transfer payment from SDR2021-00005 to CUP2021-00003. Void SDR2021-00005 T2AA&er rnaae R 3O 2o2.( Signature: Aa Xi-Nthleh Date: 9/30/2021 Print Name: Agnes in.A 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 3-0 weeks for processing refund requests. FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date// $ Ntee 1-12.445 lief I-Rrocessed: Date 77.3d/2—/ Byp(2 Invoice Processed: Date By Permit Canceled: Date, / /2i Bye Parcel Tag Added: Date By I:\Building\Forms\RegPemvtAcction_l 051 .doc