Permit Support Document }
City of Tigard • COMMUNITY DEVELOPMEIDEQTMINTat
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Request for Permit Action IliaECEIVEG
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti and-or. ats'R 2 5 2022
TIGARDg g g g �
JIT7 Of TIGARD
TO: CITY OF TIGARD 3UILDING DIVISION
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(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
: tZ11x
• ne No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Eta 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#: 5OP2022_ ODb7-Uj
Site Address or Parcel#: 1244 0 &i,) NDenq / 1 Y07 (ST.
Project Name: GM/T-i
Subdivision Name: Lot#:
EXPLANATION: CREA—E{) F3UP PE�L1�-�l'1'losavPQ
C ,d�.�_
Signature: if D C am Date: 3/2,S122.
Print Name: "Tina E,SCaie(T�
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date e/2 /2. By -1-€. Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 141 K,`ZZ, By th0 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12O)518.doc