Permit Building Division
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ct "I ' i Request for Permit Action or Refund
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City of Tigard RECEIVED
TO: CITY OF TIGARD :APR 1 2006
Permit System Administrator CITY OF TIGARD
13125 SW Hall Blvd., Tigard, OR 97223 BUILDING DIVISION
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner El Applicant ❑ Contractor fg City Staff
(check one)
Name: D 41 f /
V 0 I D (Business or Individual) M�/&/
Address: WO1— OI, Pa j't i/A/6_ r
Mailing /0 7S GJ C°(-44 /� d62 fir. 9
7Z.9/4‘0 City /State /Zip: , 4 9
Phone No.:
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PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION.
i REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: Lit AODl0 — X00 0
Site Address or Parcel #: /01,2 41 �� ,L1. 1, f w Cr
Project Name: 5 / -
Subdivision Name: /4» Lot #: /ti /�-
EXPLANATION: /06.d/ 114)10a 5 L/ redi ,--/ t/ - 7g/z...,
Signature: - I, %1.-___,��' Date: ' l Da .
Print Name: — DM / f 47, #A/5 /
Refund Policy
I. 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 Payer in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to S Admin: Date $' f Q B 'Pt Rte to Bld: Admin: Date B
Refund Processed: Date A706 B Invoice Processed: Date B .
Permit Canceled: Date , 06 B ' arcel Ta I Added: Date B
Receipt Ike - //5 Date y 3 t , Method . eG Amount $ l8 30
. I: \Building\Forms\RegPermitAction- Bldg.doc 01/20/06
CITY OF TIGARD fz-- i 1 1
BUILDING DIVISION PERMIT #: O6 — / 6 (
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 Amafto,�'
Inspection Requests (24 Hrs.): (503) 639 -4175 ;DI
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
TE ADDRES - 1 2 ) "V' V1 L)' ` 3 CLASS OF WORK:
— SUB , V ON: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: 3--f5-0 Pour Time: 0" & ---
Code # Inspection Description Confirm # Contact # Message
3 / 9 1 a 3.s= 87? y
Corrections/Comments/Instructions:
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❑ PASS ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
❑ FAIL ❑ CALL FOR INSPECTION ❑ ADDITIONAL FEES ASSESSED
Inspector: Date: Phone #: (503) 718-