Permit 1 II
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 n Applicant n Contractor Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) •
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available). VO D
n . INVOICE FOR FEES DUE (attach case fee schedule and explain below). �, //
H REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: � 2 9 X
Site Address or Parcel #: /03 G 0 ro4 v Lti
Project Name: Jc) Gyv / / vTJ /Gt�lc—
Subdivision Name: Lot #:
EXPLANATION: a/,/,kC kinS (M/d ‘ (2 76 ecyl -eems
L -OcAru Pi, /6,11 6,
Signature: Date: /(
Print Name: L
Ail
/
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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 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 onginal Payer m the same method in which payment was received. Please allow 1 -2 weeks for processing refunds
FOR OFFICE USE ONLY
•
Rte to S s Admui: Date IMAM B jr Tr) Rte to Bld: Admin. Date /p / B 4117fr -
Refund Processed: Date 1 9- By `� nvoice Processed: Date By
Permit Canceled: Date /e/20/ By Parcel Tag Added: Date By
Receipt # Date Meth d Amount $
I \ Building \I =orms \RegPerrnitAction doc Rev 07/26/07