SUB2013-00007 III City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTv i
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 S\C' f Iall Blvd., 'Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 'City Staff
;th,ek,5k
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOV'1-i/REPI-ACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: U,te32013 -coccY7 and VA-g2 D13-00025
Site Address or Parcel #: {D11QQ S v WO)n &i-.
Project Name: q KTc- (,, p
Subdivision Name: A Lot #:
EXPLANATION: Wrrn1U- no)- l C c e p t e d 6 4 1111s -llrr Q . Nvw I+- IS ' -
D 114 COLSC S wC3 (;1 I t -6000 a ,
Signature: AIWA VOA-- Date: ?JJ23) 1 t._i.
Print Name: A `na Vo acc
Vclund I�ulicy.
1. 'the Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than Afl"a of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 800o of the land use application fee for issued permits.
d) not more than 80°a of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80"s 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 hich pen nx nt a.,received. Please allow 2-4 weeks for processing refunds.
l Olt uI DICE USE ONLY
Rte to Sys Admin: Date B• Rte to 1 ._- dmin: Date ®ii,rj r
Refund Processed: Date/✓A- B .i'f Invoke Processed: Date By
Permit Canceled: Date 2/25//ff/ By ,rte• Parcel Tag Added: Date By
Receipt# Date Method .\mount S
I:\Building\Forms\RccPermitAetioadukc Rev 05/25/2ul2