Permit Support Document RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTIII ��P 71C
Request for Permit Action CI Y i I.aARU
qq PMSION
1 I t; R i] 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigarao G�
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(.7)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE 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#: (�(_4p ,2,-) - C1 c)0e'8
Site Address or Parcel#: I a �S1-I O SL.J i a i'', P lb,ex
Project Name: L-.C7 Art c j 0,1 of I N,1 S--
Subdivision Name: Lot#:
EXPLANATION:{ ,, c,Ac17kJ 04 S ct i;1 - C I c J V/ 1'(' il
( --e i a lA� J_ 60/0 (tiJet$ C✓`2q4eof
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Signature: 4 Weal Date: L4 A ? t: 4
Print Name: Q NQ11 U b-4 1')
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 f aas By k Route to Records: :Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date ..i9:63.,_ By VA- Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc