Permit i'1 ECEIVE I'
1 011 -;
Community Development . h1 p 2 0 2 . ;:1
Request for Permit Action
i i r. n CITY OF TIGAR i
1=,, ' • 1 D VISION
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 -orgov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
(chock one)
REFUND OR Naroc:
INVOICE TO: (Fuwi»tiS Tndlv:,tAha>) /ft
V 0 1 • Mailing Address: _ _
City/State/Zip:
:020, 16E= Phone No.:
PLEASE TAKE ACTION FOR THE.ITEM(S) CI:IECKEI) (1):
U CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES (attach receipt, if available).
El INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: E-6 C . D 7 7.
Site Address or Parcel #: Mar, p, . . a
Project Name: "°-:gF},g-j � e .119 i S
Subdivision Name: Lot #:
•
EXPLANATION: A.A. + !AP 1 �rt _ _ .:i_.+ ,_ : �stro •
dr
Signature: A a7= — Date: 20 I .0 z
Print Name:
li t . .' Z
d
1. The Director or Building Official may autborirc the refund pI
n) any fec which was cuonecuely paid or collected
b) not more then Af % of rho land ire application fro whin nn application is withdc wn Ur canceled before any review effort hnr been, •
c) not mnrc than 803'e of the land use application fee for roved perndot
d) nor more um 80% !,f the buildin plan review fee when an application ie ontulud before any plan review oflort has been expended.
o) riot more than NtF'e of the tauildins permit far tar ironed permier yxiot to any inspection aogersrs.
a Refunds will leo returned to the odgenal Pala in the same =hoe in which payment waa received. Plci:.c allow 1.3 hocks for pxocersin tefunda.
H.,1; oFFT(.:1: I.!ST- ONL -1
Ste to S e Admix: f I _' i a C l 4 Rtc to Bld: Morin: Data 474ail B J1 ,
ir Refund Processed: Date it B. Invoice Processed: Date
Pert:ehit Canceled: Date AgrAIM By j • Parcel T : Added: Date MOM
Dare Method Amount $
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