Correspondence IN - 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 j' City Staff
(check one)
REFUND OR Name: 4 INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
r _ CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available). V 0 1
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). 4 V /
Permit #: c iADP.,.900- 00 /o 3 /0T
Site Address or Parcel #: / 67 / 5- o c 14- fi(w)/ ** // 0
Project Name: //Jrf c — Th .6f2J, cgs
Subdivision Name: Lot #:
EXPLANATION: ��,Qt. I T - tJar �L. Q u. 1 (Zti b Pr a 6 f t12. e 0 T5 ,Ceti
Pal AC- C 5 4 Pr PPLi 1 .
Signature: 6■-_)_,jg. Date: 4t.t l 1 I
Print Name: -D f-P,61 E. �PbFj (1/4-4 S te-\`
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 pnor to any inspection requests.
2 Refunds will be returned to the onginal Payer in the same method m which payment was received Please allow 1 -2 weeks for processing refunds.
FOR OFF.IC_ E USE ONLY
Rte to S s Admin: Date B Rte to Bld_ Admin: Date /d®' B 4
Refund Processed: Date Ai 4 Byo: dr 'Invoice Processed: Date By
Permit Canceled: Date (15/2e/ By. Parcel Tag Added: Date By
Receipt # Date Method Amount $
I. \Building \ Forms \RegPemutAction doc Rev 07/26/07