ADU2021-00015 '4I � _ RECEIVED
�Z--,f d1) SEP 03 2021
D
ION
City of Tigard • C034MVMrY MVELOPM[ate 1DhPARTM
Request for Permit Action
13125;CVC'HiP.IWd a Tigard.Chtytcnt 97223. S03.716.2439•vi"MAIM of trot
TO: CITY OF TIGARD
Building Dion
i.1125 SWI lab lihd.,Trgard,0a 97223
Marx 503.71S-2439 1'u: Sn3.99 j%o T*u lboidsmKPcrnuts op�rd cw Foe
FROM: U O-Aver ❑ .%pptxmnt ❑ Crxtttsaor ❑ City Suff
REFUND OR Namr: /
INVOICE TO: ps.w.«t.+. j 7U2r► �if� S[ CiMi/) Alf'& 4
�taittnf;:'lddress: L�/off 'i tLl j� a/d [f
C;xy/Stwtrip: 7i j"d OR 9J.� 23
PLEASETAKE A(,-I'ION FOR THE ITEM(S)CHEiCKFiD(w'):
CANCOLAtOID PFRNIT APPI.IC.1110N.
RMI ND PERMIT FEES(attach asp}•of onlptul receipt and provide ciphtution below).
INVOICE?FOR FP.t:S DGF.(attach h ak ant_ i g=.ro,•ode cirli6ruti t bekvw).
Pcrrttit#: /4 Del 2, 21 -00015 .t h9 S j 2 0 2.1 -.OL?lel
Site Addres%or Purcl fl: !z!0 x �Cy I Z i rd d 71,14f Gk JZ223
Protect Name: 12,o s _SL1J !13/Pl 46j
Subdnislun Natic: _ LAX f::
IIIALANATION: iziLlLe ?. [ asp felt_
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SAgtutarc- -- Date: y/2 /3•y�) /
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