ROW2012-00095 1 • Community Development V 0 1 D
Request for Permit Action ,///f /.2-
TIGARD
4#
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: El Owner El Applicant ❑ Contractor 1 City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
El CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW20 OocFt5 '
Site Address or Parcel #: (6 O SW 71 a( Dr-
Project Name: Fink Dr,vvWa Q�piaach
Subdivision Name: Lot #:
EXPLANATION: i Crea*p.A Gale j n err o{ c* #ee rec,:;v i nO`
an otp ut+i on cof a PR . Pl ease; can
/.2 -4003'2
Signature: . .4A , , Date: 1 o 2' I -
Print Name: - Tim L,ek,rho cc 1�
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
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 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 Admin: Date By Rte to-1 Admin: Date / / /5 /Z B 1-
Refund Processed: Date V /9 By, Invoice Processed: Date By
Permit Canceled: Date / / //S /f2_ By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms\ RegPennitAction.doc Rev 07/26/07