MMD2021-00007 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I r'
,1 ■ Request for Permit Action
T c, is 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 A 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):
E. CANCEL/ ID PERMIT APPLICATION.
E RMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MMO2 ''
02\" b000
Site Address or Parcel#: 2ti uQ A%cOgCoW ` 13Q3"i QA•N t41 Cr.
Project Name: t`V RAN l'ht•(-3 SUBQiV' S i Oti1 - UDRAn/ fiZe3W I,1L 4Ii momAritiki
Subdivision Name: f b .AN m u Lot #:
EXPLANATION: pi Q4Nrm., Ce/a-n Div OF M O LAM) Ole Ft L 6/t)
p c c.el,A V1/4114Gr1 slt,)(A) ye_ Citu ra) A UP • fpt.r-A-C 5- It' GAv Cee L, nit
t 'S Yl-e I vd I C.CC) c91U j t 1 S 19 LC. • 5cC u, v.2/ G(71J0 /
Signature: �.J--` �� Date: q fr/20ZJ
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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'z, 2-1 By
Refund Processed: Date A//r L By 4(� Invoice Processed: Date By
Permit Canceled: Date p,' ,/1 By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 051 .doc