Correspondence I q
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: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEAS E.. ACTION F THE ITEM(S) CHECKED (Ai):
CANCEL PERMIT APPLICATION. V 0 1 D
n REFUND PERMIT FEES (attach receipt, if available). /O /2e /'?
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
f
n REMOVE CONTRACTOR FROM PER.MTT (do not cancel permit).
Permit #: l f r �r.Cj( -- (c) tip,.
Site Address or Parcel #: /37 $' 5` J , /ra 1 `` i r) n/ 67
Project Name: ! " U (Qj (/ (e. Z
Subdivision Name: Lot #:
EXPLANATION: C t i ),.0 e-- G C am. ( v , �(�
CeJ NO"Y)en✓Zi a ( 1 c,AicA ;1 1 a - e o' - e - S , oCe,.J1 `. /.
56 /16 ho // —9e '/33 a
Signature: ,--
ignature: - _— -- �, Pate: 02 //
Print Name: c erc�/�fc (c'J / 1 , 4
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b) not more than 80% of the land use application fee when an apphcation is withdrawn or canceled before any review effort has been expended.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 Admtn: �'� B ME Rte to Bld: Admtn: Date /p , Mil G riSrAI
Refund Processed: Date '' B 4•••A . Invoice Processed: Date B
Permit Canceled: Date , 2pAll B , VA arcel Ta: Added: Date B
Receipt # Date Method Amount $
I \ Building \ Forms \RegPerr itAction.doc Rev 07 /26/07