Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
/
7111
_ Request for Permit Action
T►GARI) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov i f
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 IN 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 (✓):
X 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 #: 130(22OZ2-On 10 O
Site Address or Parcel#: 134105 SIN I O1-Pr; AV e
Project Name: 5u9 i R
Subdivision Name: Lot#:
EXPLANATION: C e e a cip 1( OF '' MST.
P O c1 1 OO as ram-7022.-ooto Q.D
LL S Create c fY-1-1')i S v1 be 't
Signature: edC'n a ) 1?-4)C2L4 . Date: 4l 2Co/22___
Print Name: -TTNA E C, ' ec
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ' ,1(,/ '),-1, By Ic Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date VIq/3 k By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc