Permit Community Development
.14
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.ttgard-or.gov
FROM: n Owner n Applicant n Contractor ity Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Indnrdual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEAS TAKE ACTION FOR T4 E ITEM(S) CHECKED (✓):
CANCEL PERMIT APPLICA 0 1
n REFUND PERMITT FEES (attach receipt, if available). i //t� /
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: (
Site Address or Parcel #: 0-40? Sim/ C r A
Project Name: (A), ,S b f lA/0.4 /Gi a
Subdivision Name: — Lot #:
EXPLANATION: � Y ' M , r , ',V e- fret/". .A ✓M ,� - llt� t,/
C o20 //- 606 'L/ e:
Signature: ` rte . - _� Date: /l /2/ /
�J
Print Name: are21kA f a
Refund P olicy
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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 poor 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: Date larlf= B ,yam Rte to Bid: Admin. Date - .� B '
Refund Processed: Date N ,r9' B .f Invoice Processed: Date By
Permit Canceled: Date // f // / By ;! Parcel Tag Added: Date By
Receipt # Date Method Amount $
I \Building \ Forms \RegPerm itActron doe Rev 07 /26/07