Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 D
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III Request for Permit Action /0v/7.,/ .40
T i G n R I) 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 ity.Staff
iCheck(✓)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):
CANCEL/VOID PERMIT APPLICATION.
n 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#: "l111,20 2-1- IJUU I-t7
Site Address or Parcel#: /. 7(o.q s fa,{c- 64...7
Project Name: a S 6Yr-c.f.
Subdivision Name: t Lot#: ---
EXPLANATION: /04/'1 a7Ja f—G.t.x g•S,i- e-IS-7/,Y)le s Ae..,,, ,e7- A,, r .
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Signature: - Date: /1/4 ,a-1
Print Name: 13,0itii7te 7--
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 t'SE ONLY
Route to Sys Admin: Date /i, 2.15 ;i.p By 6 7 Route to Records: Date ////y/Zj By .>,3
Refund Processed: Date / By.47 j1 Invoice Processed: Date By
Permit Canceled: Date // /y/ By a Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1_0518.d c