Permit Support Document (2) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTRECEIVED
1111
Request for Permit Action MAR 7 2022
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-e} bOF TIGARD
bUILUIN(i DIVISION
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 X❑ Applicant ❑ Contractor ❑ 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 (✓):
Q 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#: Electrical permit ELC2022-00030 to be voided
Site Address or Parcel#: 11956 SW Garden Place
Project Name: ZoomCare Central Lab & Pharmacy
Subdivision Name: Lot#:
EXPLANATION: Timberline Electric created Electrical permit ELC2022-00030 online
on January 17, 2022 is to be voided. This permit will be replaced
with Electrical permit ELC2021-00682 submitted on November 15,
2021. -.64,44 Ned- 4. ' 1A 244.41.1 7/
Signature: M � :o, l Date: 03.04.2022
Print Name: Mark Steinhardt
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 3 7 7.y. By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date Si A,ZZ By k..NV Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12a518.doc