Permit Support Document V 0 I n
City Of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
11111 r
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: 0 Owner ❑ Applicant 0 Contractor ❑✓ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
ElCANCEL/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 #: MST2021-00534
Site Address or Parcel#: 10891 SW ANNAND HILL CT, LOT 1
Project Name: ANNAND HILL
Subdivision Name: Lot#:
EXPLANATION: PERMIT CREATED AS MST INSTEAD OF BUP
Signature: Date: 12/08/2021
Print Name: Eggi- Maldonado
Refund Policy
I. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Admin: Date \z\g Z\ By tw\ Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 10.A\2`22 By \k J Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_7 205l8.doc