MLP2021-00002 vol
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1/67 /
I ' Request for Permit Action
i , , , 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 ❑x 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 (✓):
(iiCANCEON.
❑ D PERMIT/VOID FEESPERMIT(attach copyAPPLICATI of original receipt and provide explanation below).
❑ INVOICE FOR FF.FS DUE (attach case fee schedule and provide explanation below).
Permit#: MLP2021-00002
Site Address or Parcel#: 14580 SW 126th Ave
Project Name: Crino Partition
Subdivision Name: Lot#:
EXPLANATION: Created by mistake. Should have been a pre-application meeting.
Now PRE202 1-0 0031
Signature: f., Date: 6/2/2021
Print Name: Agnes In 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date ro jr/ By ./
Refund Processed: Date /(///4 By ./d Invoice Processed: Date By
Permit Canceled: Date 4 'j B; .'i Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_i 51 or