Permit Support Document Community Development RECEWED
S E P 0 2 2011
Request for Permit Action
TIGARD CITY OF TIGARD
BUILDING DIVISION
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 n Applicant n Contractor F City Staff '
(check one)
REFUND OR Name: I /
INVOICE TO: (Business or Individual) j� / /( -
Mailing Address: ///
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
M - CANCEL PERMIT APPLICATION. 0 1 0
REFUND PERMIT FEES (attach receipt, if available).
fp /'La if
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
PI REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ''---1--
u P � (1 -CO 14 3
Site Address or Parcel #: l as L1' so ✓i- t-L ta-
Project Name: l " - N) \I rj a_ ' , p i l /Jd
Subdivision Name: Lot #:
EXPLANATION: e_p.,, I . T ' h A i /Z dV1 / r --- t tj &246/2. . 10 20,j,
PEkH 1 7- i PE , ,_g CH`s oz// DODCOA
Signature: � j
Date: 9 ////
Print Name: — 7 - 1)2 / 46 / i D /9 k.
Refund Policy
1 The Director or Building Official may authonze 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 S s Admin: Date 9r IWA MMI Rte to Bld. Admin: Date // ,, �' B jar
Refund Processed: . Date /9- By (.'' Invoice Processed: Date By
Permit Canceled: Date *20/ By4?71/ — Parcel Tag Added: Date By
Receipt # Date / Method Amount $
I \Building \ Forms \RegPemutAction.doc Rev 07 /26/07