Permit VOID
"P Community Development
_s-A/3
TIGARD Request for Permit Action
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-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 ( ✓):
g 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 #: SWR2013 -00101
Site Address or Parcel #: 11565 SW Durham Rd, #100 Tigard, OR 97224
Project Name: Dr. Auzin
Subdivision Name: Lot #:
EXPLANATION: Created in Error. EDU was a credit. See PLM2013 -00116
Signature: iilLikeeti (1 c Date: 4/25/13
Shirley Treat
Print Name:
Refund Policy
1 The Director or Building Official may authonze 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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 returned to the ongtnal 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 Admm: Date By Rte to Bldg Adnun: Dates 6 /3 B 1 / 1 7
Refund Processed: Date B■ Invoice Processed: Date B
Permit Canceled: Date 4' /3 By i' i Parcel Tag Added. Date By
Receipt # Date Method Amount $
1• \Building \ Forms \RegPermitAcuon.doc Rev 07/26/07