Permit Support Document (3) Y
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
9//J/z-f
Request for Permit Action
1 :' ,A R.t) 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. ov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Z. .
Phone o.:
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#: /f17,Fciit J -ci C Y Q
Site Address or Parcel #: //' 5 EL,.) )/-t,
Project Name: 7 i "67441,w�SS Ave.(
Subdivision Name: Lot#:
EXPLANATION:
E00SS.
Signature: Date: //0l
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /� 2-j By , Route to Records: Dar" f By,le"
Refund Processed: Date ' By ,d 2/
° Invoice Processed: Date By
Permit Canceled: Date //p/2./ By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 2051 .doc