Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
T I G A R C) 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 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/ .:
Phon- o.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Er...rANCEL/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 #: 6Z/t/PoDdJ —o 1 c�
Site Address or Parcel #:
Project Name: /1
Subdivision Name: Lot#:
EXPLANATION: 4....ei//
f l ST• /--) p w - 9 iw d&1-c i& -
Signature: td� 40-7 ee!, Date: 41-73--2 f0�
Print Name: ,,yz vde/J
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /a 7 / By , Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date t`k2.`7Z. By / Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc