Permit Support Document (4) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action
l-'G;;A R D 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):
Ef -ZATNCEL/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#: / 175C-80d-) -oucd ei
Site Address or Parcel#: /I' S'J,
Project Name: ,yJr-as,i A. Ayffe,..._
Subdivision Name: ' Lot#:
EXPLANATION: 1
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6
Signature: Cam/ � - � Date: /7(.,d1/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONI Y
Route to Sys Admin: Date f 6 if By Route to Records: Date 9 AO' 2, By dL ,
Refund Processed: Date n// ' By Invoice Processed: Date By
Permit Canceled: Date 9rf1e
By
O Parcel Tag Added: Date By
I:\Building\IForms\RcgPermitAction_12051 .doc