Permit v u I L P■1OISIAKI
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ZIOZ S U - Inc'
: IN I. ' Request Permit Action
T I c_i,, u. f) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigar pagan
TO: CITY OF TIGARD
Building Division Services Supervisor
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) ,/.®,c L g /;/ t .,' L J A i t..., 1L
Mailing Address: 4")-- b J' („2 (-4-, 5,..,='1.` (00
City/State /Zip: 1._..4... 0 5 ,._ D D L 170 3 5 ---
Phone No.: - -9 S7 — 7
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
MI CANCEL /VOID PERMIT APPLICATION.
U REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: 1' l ,919 I I —OD / 3 o fieuX v?0// —DO // 7
Site Address or Parcel #: 12-405 ou Ivr \i, ', er—
Project Name:
Subdivision Name: Lot #:
EXPLANATION: C/C,...., /1c..4.-^ / ` ti s o L -F
( M ao l -- Cb 1 7 ' l
Signature: Date: 7/Z / ( 2
Print Name: i'T ^e/4 y ,..-5- 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
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 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date A[ r Rte to Bld: Admin: Date 7A® B -•?
Refund Processed: Date /i/ 9- By Invoice Processed: Date 7 fP / By .
Permit Canceled: Date 7AV/ . By 4* , 'arcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012
CITY OF TIGARD FEE AND PAYMENT HISTORY
i R _ 13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
iUGARD
MST2011 -00130 - 12603 SW MOUNT VISTA CT, TIGARD, OR 97224
Revenue Payment
Fee Description Account Number Fee Amount Invoiced Paid Date Paid Method Receipt # Due
DC Provision Review, SF - Ping 100 -0000 -43112 $65.00 $65.00 $65.00
DC Provision Review, SF - LRP 100 -0000 -43117 $10.00 $10.00 $10.00
Plan Review - Building 230 - 0000 -43106 $750.00 $750.00 $750.00 7/26/11 Check 183410 $0.00
Totals for Fees $825.00 $825.00 $750.00 $75.00
Receipt # Payment Method Check # Pavor: Receipt Date Receipt Amount
183410 Check 33259 Stone Bridge Homes 07/26/2011 $750.00
NW LLC
Total Payments: $750.00
Balance Due: $75.00
•