Permit I e ° Community Development
TIGARD Request for Permit Action RE I v
CE ED
0 ° .5 2009
TO: CITY OF TIGARD �FTIGt8D
Building Division Services Coordinator C,1'(Y Weal
13125 SW Hall Blvd., Tigard, OR 97223 BU11A1NG
Phone: 503.718.2430 Fax: 503.598.1960 www.rigard-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):
❑ CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
El REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: [.()2. boor - DOD g
Site Address or Parcel #: / $ 9 71 ( 96' 4
Project Name: AL ETC fl-f it ZOOegb S
Subdivision Name: I ` � Lot #: l .
EXPLANATION: a, 6 t et p, L1-f i M-mb q l c �-u
10,2 "o / 3 1--to
--o ; ' c5 f t_ a wk A00 ? - Dtaf; t Y•
Signature: _ Date: / / /'/ Q 9
Print Name: - -- DE6 I 2 I'Iaf) /4/
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 retumed 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 Admire: Date /j y o4 y WA Rte to Bldg Admin: Date By
Refund Processed: Date /J4 By 6r. Invoice Processed: Date By
Permit Canceled: Date `), s, /p 9 By , - arcel Tag Added: Date By
Receipt # Date Method ' Amount $
I:\ Building \Forms \RegPemutAction.doc Rev 07/26/07