Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
r
Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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: 0 Owner 0 Applicant 0 Contractor EJ 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 (✓):
❑r CANCEL/VOID PERMIT APPLICATION.
O REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
O INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: BUP2022-00033
Site Address or Parcel#: 16791 SW LEAF LN
Project Name: Creekview at South River Terrace
Subdivision Name: Creekview at South River Terrace Lot#: 2
EXPLANATION: Created BUP2022-00033 in error. The correct one is MST2022-00028.
Signature: 'Q'wa > 13 * Date: 1/28/2022
Print Name: Tina Escalera
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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\t2.iN ZL By T . Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 4 t"AIL By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc