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Correspondence Community Development TIGARD Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: n Owner ❑ Applicant ❑ Contractor ity Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City /State /Zip: Phone No.: PLEASE - AKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL PERMIT APPLICATION. V 0 n REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). /© / /PP ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). /COY-- Permit #: Site Address or Parcel #: 14 C 9�y Project Name: EtI t(L.)l (Air /1 co-) S Subdivision Name: Lot #: EXPLANATION: C e, 4ee p ' PLC- t S LCA4, ve beeA) cw h pc-A/Yv\ . L7 -122, [(— ve /e 7 L / Signature: Date: Print Name: Or e ,tA P f V u� Refund Pokey 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fee which was erroneously paid or collected b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended c) not more than 80% of the land use application fee for issued permits d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) 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 g` c /( By /g 7 Rte to Bld! Admin: Date , MEM B .�r. Refund Processed: Date Ay - B . 4'4 Invoice Processed: Date By Permit Canceled: Date /4/, /// By jr ,%% Parcel Tag Added: Date By Receipt # Date Method Amount $ I \Building \ Forms \RegPerrmtAction doc Rev 07/26/07