Permit (.a
.
Building Division _
T IGA R D Request for Permit Action R f`®
JAN — 4 LUU'
TO: CITY OF TIGARD CITY OF TIOA' D
. • Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov BUILDING Nli'��
FROM: ❑ Owner ❑Applicant El C ontractor City Staff
(check one) /
REFUND OR Name:
INVOICE TO: (Business or Individual) /fte
VOID Mailing Address:
City /State /Zip:
// 4,1et
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
, /
. S CANCEL. PERMIT APPLICATION. ,,,, . . )
[7] REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain bel ).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel p7pew e-g—
Permit #: A:0 e) A007 — COO /v (/ 2
Site Address or Parcel #: /D 3U 0 j � ekeJ' u,Q, 6 #o�C)
Project Name: J/.(_ UAL j t
Subdivision Name: 1\j/14 Lot #:
N __, EXPLANATION: � L LA M Per, je 0.43 I - CT!>_ ALL- X /2E5 .
AlZ P P_E P L A-0_ E t--t e J-F ) -9 /t aga) Ebei '• 5 iocikc
01,/ c F -> .
Signature: i• a661---144-4-06 / Date: / V D
Print Name: ) 4 f_ fI7)/91
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) 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 Sys Adrnin: Date / V D7 : y L ,7 "P Rte to Bldg Admin: Date By
Refund Processed: Date /V By Invoice Processed: Date By
Permit Canceled: Date / 9 - 7 B , 'I" Parcel Tag Added: Date By
Receipt #k. Date / //l Me od Amount $
I: \Building \Forms \RegPermitAction.doc Rev 05/24 SEW 77,---1.1_,/ S#EZ -7.—