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: Community Development MAR 2 7 2009
� Request for Permit Action
CITY OF TIGARD
(VISION
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW flail Blvd, Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: ❑ Owner [] Applicant 01 Contractor ❑ City Staff
(check one)
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REFUND OR Name: _
INVOICE TO: (hlusintss os lndividua0 Rod i cr 1M ` 1 e C
Mailing Address: , �. l o w nu VI Y ' LOA IVIC,
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City/State /Zip: F6M.arld 1 Ole_ C112.0
Phone No.: 505 223 5e10 g
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL PERMIT APPLICATION. I ,5s M
1
a. REFUND PERMIT FEES (attach receipt, if available).
0 3
❑ INVOICE FOR. FEES DUE (attach case fee schedule and explain below).
El REMOVE REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). i 1 9- fi 7� • ( 9 3 �%' .
Permit #: E L& 2OOZ — OC12 ,�/I AS. �
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Site Address or Parcel #: 2S 1 I MA. . --- 004 CX I v D
Project Name: 0 ) jel dL - y - a l t ouch .
•
Subdivision Name: Lot #: 61 K2
EXPLANATION: p i C]. n ok (l o p _ 11° el
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Signature: i L.iL! E Date: 31 /O9 .(0
Print Name: \ akAlt) P &VCS •
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1. The Director =Building Official may authorize the refund o$ t ^J
a) any (cc which saes euoaeoasly paid or collected. II p(D ((i�
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. V 1
e) 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. r
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 titian method in which payment was received. Please allow 1 -2 weeks for processing refunds. l
FOR ' l rcE US U.: ONLY
Rte to S , : Admin: Date M Rte to Bid Admin: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: _ Date B
Receipt # Date Method Amount $
I :\ Building\ Forms\RegPeratitAcdon.d Rev 07/26/07
21A0OR �OuOOCc O 11555
E0 3917d WW0013Mod b E0S
0Z0EZZ EZ :LZ 600Z/9Z/E0
CITY OF TIGARD RECEIPT
i 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 27200200000000004505 - 11/26/2002
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2002 -00265 [TAX] 8% State Tax 100 - 0000 - 207020 $6.00
ELR2002 -00265 [ELPRMT] ELR Permit 220 - 0000 - 431510 $75.00
Total: $81.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
CreditCard TAAA CONV 11/26/2002 $81.00
Payer:
Total Payments: $81.00
Balance Due: $0.00