Permit . .
• . Community Development
VOID
•
Request for Permit Action //ft/A: .er
TIGARD
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: ❑ Owner ❑ Applicant ❑ Contractor ® 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 (1):
/1 �CANC�u ► ELPERMIT APPLICATION. _
OF lIC LP ERMIT FEES (attach receipt, if available). / /DNS F�
• INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: BUP2012 -00202
Site Address or Parcel #: 12275 SW Tippitt P1
Project Name: Loewer
Subdivision Name: Lot #:
EXPLANATION: BUP created in error, should have been MST . Please see MST2012 -00284
Please transfer funds over (if possible) Thank you
Signature: , ,j ■littat Date: 11/20/2012
Shirley Treat
Print Name:
Refund l'olicy
1. The Director or Building Official may authorize the refund of:
a) any fcc 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b) not more than 80% of the land use application fee when an application'is withdrawn or canceled before any review effort has been expended.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 HO% of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) 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 Bldg Admin: Date // Zr / 2_- By ' '
-
5 ,FEL- BrainT'd" Processed: Date 24/, Z By. Invoice Processed: Date By
Permit Canceled: Date 4/ z4// Z By ,!- . Parcel Tag Added: Date _ By
Receipt # Date Method Amount $
• 1: \ Building \ Forms \RegPermitAction.doc Rev 07/26/07