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Permit Support Document
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT i IN ■ r Request for Permit Action 1 ,t,,l:l) 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: ❑ Owner 101Applicant ❑ Contractor ❑ City Staff Chcck(1)one REFUND OR Name: INVOICE TO: (Business or Individual) '—t) to jet F iN itJ a't111 t E1 ` Mailing Address: / 2 CO7 ,o L ' 3 3 71" City/State/Zip: ‘,/4n1C..c.1 0+c�t2, A 98 a=6 `Z Phone No.: ,jG 3- 28 Z - o '7 9 -3 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL/VOID PERMIT APPLICATION. Ef 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 #: -- ..M2_o7Z - obI13 Site Address or Parcel #: //, Z. i'1 5',t..L) . ( u3 r1' Ava- j 174AR_p , © 2 ("7 L Z.(/ Project Name: -k- / 3 0 .531 Subdivision Name: Lot#: EXPLANATION: 34,0e of- woRy..._ t A c awlc aG.P..►C sPo. - •2E/Alcz. . t4c , m.)N.Ic0tz d .t.1�a +c A/of G6 A F„ // i..,,h•t .. Sc121/iGcs --AEI)In(..c=-A4t�V-i" • Signature: -, c fs ,. Date: S�l4 Z Print Name: Y z 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 • Not more than 80'%0 of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 S 2 By N Route to Records: Date By Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_I20518.doc ,a> G ma i I D&F Plumbing Permits <permits@dandfplumbing.com> Order Receipt 9272407 1 message PayGov<no-reply@paygov.us> Thu, May 12, 2022 at 10:28 AM To: permits@dandfplumbing.com This email is a confirmation of your Online Payment for PERMIT CENTER Cardholder Name: Richard Riggins Telephone : : (503)282-0993 Credit Card Type : MasterCard Last 4 digits : 5XXX XXXX XXXX 9942 Confirmation Number:9272407 Card Auth Code : 682650 Transaction ID : 2045408805 Agency Payment Amount : $81.20 Convenience Fee : $2.44 Total Amount Charged : $83.64 First Name:Richard Last Name:Riggins Your payment to PERMIT CENTER has been processed by PayGov, LLC. NOTICE.Two charges will appear on your credit card or bank statement. One is for the Tax, Fine, or Fee owed to the government agency and will reflect the name of the agency. The other is for the convenience fee assessed by PayGOV.US and will reflect"Convenience Fee"on your statement. For questions or concerns contact PayGOV.US at 1-866-480-8552.Transaction disputes will result in a$40 charge to the cardholder.