Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEPRECEIVED
1111 = 4 Request for Permit Action LP. : 2: ;
I I c ,\R f) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.riga3dd�,b oyIGpRD
UYLulivU litVISIONi
TO: CITY OF TIGARD VO
I l
Building Division ''
13125 SW Hall Blvd.,Ti ,OR 97223
Phone: 503-718-2439 ax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner Applicant 0 Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Cr S A S-tt, /, ,,, ` ' { �,1CC , j/
Mailing Address: tel !9 7 S �/"/,�' i,/'! „f Loa L(!/cf
City/State/Zip: k,GC t 57Y0 t
Phone No.: 5'A \ - 2 39 j
PLE E TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/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#: (l✓ -- 2-0`U — 00\c
Site Address or Parcel #: 9 0`_P SW id 6.S I*11J C1 561 U Pc12.. " ►`..S.0 4
Project Name: 4VR-, (l n
C-F\n . C Q 50}
Subdivision Name: Lot#:
EXPLANATION: h i S J)CL S LkA (O e-`O1A 01, I
u:k `c L( ' 1r G C 0.4- 4-6 ll i-- ��
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Signature: 6-L1 `?q 1,4 p Date: /2./23/2/
Print Name:
Jtefund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
l Mt (.>i I l( 1 l �l; U\l \
Route to Sys Admin: Date \2‘Z3 2\ By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 1\vL.\ Zi_ By Parcel Tag Added: Date By
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I:\Buildin \Foams\Re Pern itAction_120518.doc
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