Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV 0 I
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= Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • __vw.ti a•d-_ . ov
TO: CITY OF TIGARD APR 5 2022
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 CITY OF TIGARD
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPe IWIR
FROM: ❑ Owner ❑ Applicant ❑ Contractor ty 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 (1):
r' 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#: j�(�P O?- - a()O F3
Site Address or Parcel #: PI/KS— Set) G l7 71,
Project Name: HL Oc
Subdivision Name: Lot #: —
EXPLANATION: e eza lc A pc 5 We- 2 ?,/
pvi Pi-La 17r `Jr.-ii-r. .t het(it 4 b).2—od 9y
Signature: /d� Date: Ll/5
Print Name: Tk l•r > hke, ee ./
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 41 .2_2_ By 10711111 Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date s4tz. z _ By 1I1 Parcel Tag Added: Date By
1:\Building\Forms\RegPermitAction_120518.doc