Permit Support Document •
■ Community Development
r i c n 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 ( ✓):
Ea 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).
PS) #: a • • •• - •• • • _ • P 2Q\0 46 103
• __z ■ \ a
O i te Address or Parcel #: nn.to 4 p` c CI ca C1.✓PS S C1(1 .akrYL'lf o ld, •
0 Project Name: \ a FZ
,01`7 Subdivision Name: Lot #:
EXPLANATION: 1J 6 O %.(_. 'k ? Q Th A `]] pk ry vS ci,
f 2: : ; , 4
(iJ trtk A\ 1 ri � Ven A Q�' 0 prom v
Signature: (j a Q 0 111J t Date: • LJ • ‘ n
Print Name: ,_ Of aA n Q � Q fl flay a0 /0 -eV/e/ -' / . -00/0-5
/o /e y
Refund Policy / 03 ..s7 106
1. The Director or Building Official may authorize the refund of: 1 - O0 /9/ — 7r1cZ'. =d /0 -DV /y-S
a) any fee which was erroneously paid or collected. i� Zrii
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review €ffol been expended.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 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 Admin: Date By Rte to Bldg Admin: Date /.2 4.2.6 /3 By ,t ∎'/ •
Refund Processed: Date A( 4 B Invoice Processed: Date B
,
Permit Canceled: Date /e /0 By, L Parcel Tag Added: Date B
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07