Permit IN :.. Community Development - . i4 ; p
TIGARD
Request for Permit Action C L ` 4 .- ` •j V L D
• APR 6 - 2008
TO: CITY OF TIGARD C. !TV f,..: ; ;.;'t ,.O
Building Division Services Coordinator au:.. !p
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: N/A
INVOICE TO: (Business or Individual)
Mailing Address:
v City /State /Zip:
/2f/ Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
® 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 #: BUP2007 -00169
Site Address or Parcel #: 10115 SW Nimbus Ave Ste #350
Project Name: Gentle Dental
-Subdivision Name: Lot #:
EXPLANATION: Per Eric Lanciault, architect of record, their client has decided not
to pursue this project at this time.
Signature: ,_ A ' 1 . 1 6 , , i A Date: 4/24/08
ebbie Adamski
Prim Name:
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 S s Admin: Date /f 25 UMW: Rte to Bid: Admin: Date zi1. B •'i
Refund Processed: Date ,/ / `9 By Invoice Processed: Date By
Permit Canceled: Date 7fla /per By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \ReqPermitAction.doc Rev 07/26/07