MMD2020-00022 V
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT g2.0/20 420
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Request for Permit Action
T I G A R D 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 Er City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAICE CTION FOR THE ITEM(S) CHECKED (1):
CAN VOID PERMIT APPLICATION.
FUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: alAMDW20 00022/
Site Address or Parcel#: ISO 0 -Ca) L(f>1 i./— S /
Project Name: Sears
Subdivision Name: Lot#:
EXPLANATION: (' iF ft'd I h P.►rYDr r�e� ( 10 orrooe , to M LP Zp 2 ) -6 D0CI S
Signature: / kv ` _ Date: (O12I2D
Print Name:
tiV eS (✓l Kat/it—
jl_gfund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. AB 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 - 24/26 By Refund Processed: Date/I//.+ 1 Invoice Processed: Date By
Permit Canceled: Date , /21 By. 7 9 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 518 oc