Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
III r
Request for Permit Action y_
T I .;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 ❑✓ 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 (✓):
0 CANCEL/VOID PERMIT APPLICATION.
0 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 #: MEC2021-01011
Site Address or Parcel#: 7405 SW TECH CENTER DR, 120
Project Name: LEKA PLAYLAND
Subdivision Name: Lot#:
EXPLANATION: Created as residential instead of commercial. Replaced w/ MEC2021-01032
Signature: Date: 01/03/2022
Print Name: Eggie M donado
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admire: Date k 3 Z,Z By SM Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date A\\t.\2z- By ) Parcel Tag Added: Date By
I:\Building\Forms\RegPermitA cti on_120518.doc