Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I D
111 M
Request for Permit Action
T i G A R 1) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.ti Tard-or. rov
C . ED
TO: CITY OF TIGARD APR 4 2022
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 CITY OF TIGARD
Phone: 503-718-2439 Fax: 503-598-1960 TigardBL L{ OW0d-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ' 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):
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#:
Site Address or Parcel #: La3 4. $ l OC77;5.,, `'f✓�
Project Name: / "�
Subdivision Name: �— Lot#:
EXPLANATION:
,5( is v✓s si
t ,
Signature: Date: //c f/z Z
Print Name: ,�fI'r (1/ii/huee
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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,-/ s/ By P-, Route to Records: Date By
Refund Processed: Date By nvoice Processed: Date By
Permit Canceled: Date U I,L By f)l Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 518.doc