SGN2007-00109 IN : " Building Division
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Permit System Administrator
13125 SW I-Iall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor rity Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ei_tL} -s{c_, s-tIa) S-r (,S
v O y E � Mailing Address: /��5/ �,/P&— &DO00.S FGA-( R-I6
C � 7 City /State /Zip: LAK 0 ,S,(2)0600 J O7-- q 7v 3,
/ Phone No.: 5D3 6 .z9 - 3'45
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): .
C ANCEL PERMIT PPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: SC,-' N c2 0.07 l'O /d 9
Site Address or Parcel #: / a.? i (A Z-/— Grp) 14-
P roject Name: /I2/ES i &s-CO►) Lae L? 1 (-
Subdivision Name: Lot #:
EXPLANATION: 664 .S - 1.e. - S( 64.) 5J- (S TDL5 1--1 R 50 e ice 4 61, -
Signature: J/kttiZZi 0 '(,Lt Date: 6/14(01
Print Name: " `
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80 of the land use application fce for issued permits.
c) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bld•'1' : n Date 4 7 By .,i
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 4,/�/0 7 By,e Parcel Tag Added: Date By
Receipt # Date // / Method Amount $
1: \ Building \ Forms \RcgPetmitAction.doc Rev 05/24/06
CC6 7 3