LLA2018-00001 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(i)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
-�(11
J; ❑ CANCEL/VOID PERMIT APPLICATION.
N� ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
A �� ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
' �� Permit#: L LA ZO 1$-0Q d 0
Site Address or Parcel#: 10-2,O SW 72.4 Avt, Trams►, 0 93"ZZ 3
Project Name: -7-2'j Av4, Apv-6114
Subdivision Name: — Lot #: —
EXPLANATION: Ns, kr 36 rare LL42. e`00001 AV,T20 -Oo0O7_
r Fk D Lpt,4,+
Signature: x (-4401-k Date: 1-2 1-18
Print Name: Sahull (I la,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 0.2 /% /C B
2,1 �4 d Processed: Date /// /f� By Invoice Processed: Date By
ft"' Permit Canceled: Date 4- B Parcel Tag Added: Date By
I:\Budding\Forms\RegPermitAction_0923 4.doc