Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IPIII r Request Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 4 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):
E CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CO TRACTOR ON PERMIT (do not cancel permit).
Permit #: 1. Mge) t 3 — OCR l 3
Site Address or Parcel #: (1 5(05 Ajj 'Dt u F/--/ KTj The
Project Name: ---- A I.A.z t t e
Subdivision Name: Lot #:
EXPLANATION: (woe, l,, p,„2.,„ V__H C `tj /, SP C -TS b a 0
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Signature: ° Date: 5 /to /I3
Print Name: 0 jibe?*.i Cr 14b Pr M 5 k4
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date nlL er Rte to Bid. Admin: Date ®U JT
Refund Processed: Date /Y 4- By .!'f Invoice Processed: Date By
Permit Canceled: Date > /,.3 By4W Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \ Building \Forms \RegPemritAction.doc Rev 05/25/2012
Record Details Page 1 of 2
Record ID: PLM2013 -00134
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File Date: 04/25/2013
Application Status: Received
Application Detail: Detail
Application Type: Building /Com /Plumbing /NA
Address: 11565 SW DURHAM RD. 100 TIGARD, OR 97224
Owner Name: DRT PROPERTIES LLC
Owner Address: 9805 SW CHOCTAW ST, TUALATIN, OR 97062
Application Name: Dr. Auzins
Description of Work: (2) capped fixtures
Parcel No: 2S110DCO2400
Contact Info: Name Organization Name Contact Type Relationship
Licensed Professionals Info: Primary License Number License Type Name Business Name Btu
Yes 192494 CCB
Job Value: $0.00
Total Fee Assessed: $0.00
Total Fee Invoiced: $0.00
Balance: $0.00
Application Spec Info.: Received Date: 04/08/2013
Received Method: In Person
Received By: STREAT
Type of Use: SF
Class of Work: ALT
Type of Construction: _
Number of Stories:
Occupancy Group: _
Expiration Date: _
Application Spec Info. Table: REVISIONS
Item Number Description Requested Date Requested by Received Date Received by Approval
Workflow Status: Task Status Status Date Ac
Application Submittal
Revisions
Building Review
Planning Review
Engineering Review
Arborist Review •
Permit Coordinator Review
Post Review
•
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Issue Permit
Inspections
CofO
Condition Status: Condition Name Status Apply Date Severity x" �!
Application Comments: View ID Comment Date
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