Correspondence li If
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 ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or lndivi 1
Mailing Address:
City /State/ _ip:
Phone o.:
PLEAS AE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICATION. V 0 1 0
REFUND PERMIT FEES (attach receipt, if available). b /2o ///
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). 444--
Permit #: is t-C- 9.4 1l — 00546 n
Site Address or Parcel #: l U U I V t 'mbtAS , - (fX-
Project Name: pjMlotAs
Subdivision Name: Lot #:
EXPLANATION: - - _ ! r•nr t 1 N C ft
Cl�.) S ��M Nett) ) p-evr'( EL-49 (o,
Signature: ate: /, 1( 7/
A-
Print Name: A - 1. C
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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
c) not more than 80% of the building permit fee for issued permits pnor to any inspection requests
2 Refunds will be returned to the ongmal 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 f 9 (I B As _ Rte to Bld: Admin: Date 6BTa' B .il9►
Refund Processed: Date /✓ .9 B ice• Invoice Processed: Date By
Permit Canceled: Date /0/z0/ B .j "• — Parcel Tag Added: Date By
Receipt # Date Method Amount $
I \ Building \ Forms \RegPermttAction.doc Rev 07/26/07