ZIL2021-00018 0I rj
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /'///y/z-/ ide
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 El City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) American Zoning Services
Mailing Address: 3900 Beachcomber Dr, Yukon, OK 73099
City/State/Zip:
Phone No.: 405-406-9605
PLEA TAKEACrION FOR THE ITEM(S) CHECKED (1):
CANCE ID PERMIT APPLICATION.
ND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 21�-20Z I-act O I4'
Site Address or Parcel #: 13315-13221 SW 68th Parkway
Project Name:
Subdivision Name: Lot#:
EXPLANATION: Please cancel our request for a Zoning Letter, our client no longer requires our
report.Thanks and I apologize for any inconvenience!
Signature: , ) Date: 10/25/21
Print Name: Rhonda Cain
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 B Route to Records: Date / y B 4.12
Refund Processed: Date fit// By J/ Invoice Processed: Date By
Permit Canceled: Date / By if, Parcel Tag Added: Date By
l:\Building\Forms\RegPemutAcdon_1 18.d c