Permit Building Division
4 " 40„ i ��� Request for Permit Action or Refund
City of Tigard
TO: CITY OF TIGARD
Building Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960
FROM: ❑ Owner ❑ Applicant / g] Contractor City Staff
(check one)
Name:
(Business or Individual) k prt�� r aCq P f. mP 1�
\I 0 0 Mailing Address: l ?-' -o 0 d J ) `a Lox) Y
City /State /Zip: Tu.a L,,ar1-1 'pi ORS q-7o (�
Phone No.: 5D3- (ocl a -59
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
1- CANCEL PERMIT APPLICATION.
R . REFUND PERMIT FEES.
REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: Lt-i o5 - 57 3
Site Address or Parcel #: ( I -p 1 }7,9 i ,Ca ST WV
Project Name: ■T (-
Subdivision Name: M e- Lot #: f
EXPLANATION: D. t c p sc (` t CT - ,
�c � 77 b M C1-lo M Co n1 i RA- a,TUi2)
S & ,° S-- 09 `15
Signature: / A c i ' I Date: /4/0..
Print Name: 44, 4'0,9-7445k
Refund Policy
1. The Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payee in the same method in which payment was received.
FOR OFFICE USE 'ONLY.,
Rte to Sys Admin: Date /0MMIEMIW1 Rte to Bid: Admin: Date /O td 0S By.
Refund Processed: Date fo 7® B ,ii Invoice Processed: Date By
Permit Canceled: Date !d to oS B •"r Parcel Ta: Added: Date By
Recei it # - , Date b- 65 Method Amount SCAIMeir Sb 4,()
I: \Building\Forms\RegPermitAction 09- 19 -05.doc