Permit (217) VC) i
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
: Sal Request for Permit Action �/3 �� �
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T i G A R[) 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 ❑ Applicant ❑ Contractor City Staff
Check(V)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):
KC 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#: 'PLC ZOZ.\ - (7C3b-30
Site Address or Parcel #: WA SO &o r bee. ?\aC&.
Project Name: 8 C \ ‘ I.3 1
Subdivision Name: Lot #:
EXPLANATION: EAecvr;,11 c,e,rv,,•,k- was c rec c wkv
IFF'SIOZA -aiX$0, w?►.• %V SVitit,kD 1,lq•-1,. 62en k 001g4.21 crier]
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Signature: tik----------' Date: 2{eA Z.1
Print Name: \ 4r, Uc n0r1.•(eaA�
Refund Policy JJ
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date j/3 2/ By- Ir
Refund Processed: Date A/`A— By (/ Invoice Processed: Date By
Permit Canceled: Date 2'� Byj Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_I_0518.doc