Permit Support Document ® i
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
71 Request for Permit Action
TIGARD 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 Q City Staff
Check(✓)one
REFUND OR Name:
(Business or Individual)
TO:
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
O CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
O INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: MST2021-00533
Site Address or Parcel #: 10893 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
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 34 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date \Z t/6 2.‘ By EV\ Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date \`\Z\22, By 1s1 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc